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Fierro V, Mazzuca C, Urbani S, Dahdah L, Calandrelli V, Valluzzi RL, Giulio D. Perspectives in precautionary allergen labelling of prepackaged foods after the FAO/WHO consultation. Curr Opin Allergy Clin Immunol 2024; 24:166-170. [PMID: 38547411 DOI: 10.1097/aci.0000000000000979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
PURPOSE OF REVIEW The purpose of this review is to provide an overview of the perspectives regarding precautionary allergen labelling (PAL) of prepackaged foods following the consultation conducted by the Food and Agriculture Organization (FAO) and the WHO. RECENT FINDINGS The FAO/WHO consultation provided a comprehensive assessment of the current status and practices of PAL implementation worldwide. One of the key findings highlighted by the Expert Committee was the need for improvement in existing PAL systems. It was noted that many countries lacked uniformity in PAL practices, leading to inconsistencies in labelling and potentially misleading information for consumers. Furthermore, the consultation emphasized the importance of PAL being risk-based, taking into account both the amount and frequency of unintended allergen presence (UAP) in food products. SUMMARY The FAO/WHO consultation shed light on various perspectives and challenges associated with PAL of prepackaged foods. Key findings emphasized the need for improvement in existing PAL systems, including the adoption of a risk-based approach, standardized regulations, and enhanced transparency. Moving forward, collaborative efforts between regulatory agencies, food manufacturers, and consumer advocacy groups will be essential in developing effective PAL strategies that prioritize consumer safety and well being.
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Affiliation(s)
- Vincenzo Fierro
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital IRCCS, Rome
| | - Carmen Mazzuca
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital IRCCS, Rome
| | - Sara Urbani
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital IRCCS, Rome
| | - Lamia Dahdah
- Pediatric Allergology Unit, Bambino Gesù Children's Hospital IRCCS, Rome
| | | | | | - Dinardo Giulio
- Department of Women, Children, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
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2
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Golden DBK, Wang J, Waserman S, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Abrams EM, Bernstein JA, Chu DK, Horner CC, Rank MA, Stukus DR, Burrows AG, Cruickshank H, Golden DBK, Wang J, Akin C, Campbell RL, Ellis AK, Greenhawt M, Lang DM, Ledford DK, Lieberman J, Oppenheimer J, Shaker MS, Wallace DV, Waserman S, Abrams EM, Bernstein JA, Chu DK, Ellis AK, Golden DBK, Greenhawt M, Horner CC, Ledford DK, Lieberman J, Rank MA, Shaker MS, Stukus DR, Wang J. Anaphylaxis: A 2023 practice parameter update. Ann Allergy Asthma Immunol 2024; 132:124-176. [PMID: 38108678 DOI: 10.1016/j.anai.2023.09.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 09/29/2023] [Indexed: 12/19/2023]
Abstract
This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.
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Affiliation(s)
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Alyssa G Burrows
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Heather Cruickshank
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | | | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Cem Akin
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ronna L Campbell
- Department of Emergency Medicine, Mayo Clinic, Rochester, Minnesota
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - David M Lang
- Department of Allergy and Clinical Immunology, Cleveland Clinic, Cleveland, Ohio
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - John Oppenheimer
- Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-Rutgers New Jersey Medical School, Newark, New Jersey
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | | | - Susan Waserman
- Division of Clinical Immunology and Allergy, McMaster University, Hamilton, Canada
| | - Elissa M Abrams
- Department of Pediatrics and Child Health, Section of Allergy and Clinical Immunology, Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Jonathan A Bernstein
- Division of Rheumatology, Allergy, and Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Bernstein Allergy Group and Bernstein Clinical Research Center, Cincinnati, Ohio
| | - Derek K Chu
- Department of Medicine and Department of Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Canada
| | - Anne K Ellis
- Division of Allergy & Immunology, Department of Medicine, Queen's University, Kingston, Canada
| | | | - Matthew Greenhawt
- Section of Allergy and Immunology, Children's Hospital Colorado, Department of Pediatrics, University of Colorado School of Medicine, Denver, Colorado
| | - Caroline C Horner
- Division of Allergy & Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Dennis K Ledford
- James A. Haley VA Hospital, Tampa, Florida; Morsani College of Medicine, University of South Florida, Tampa, Florida
| | - Jay Lieberman
- The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Matthew A Rank
- Mayo Clinic in Arizona and Phoenix Children's Hospital, Scottsdale and Phoenix, Arizona
| | - Marcus S Shaker
- Geisel School of Medicine, Hanover, New Hampshire; Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire
| | - David R Stukus
- Nationwide Children's Hospital and The Ohio State University College of Medicine, Columbus, Ohio
| | - Julie Wang
- Icahn School of Medicine at Mount Sinai, New York, New York
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3
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Conway AE, Golden DBK, Brough HA, Santos AF, Shaker MS. Serologic measurements for peanut allergy: Predicting clinical severity is complex. Ann Allergy Asthma Immunol 2024:S1081-1206(24)00017-6. [PMID: 38272114 DOI: 10.1016/j.anai.2024.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 01/14/2024] [Accepted: 01/15/2024] [Indexed: 01/27/2024]
Abstract
Allergist-immunologists use serologic peanut allergy testing to maximize test sensitivity and specificity while minimizing cost and inconvenience. Recent advances toward this goal include a better understanding of specific IgE (sIgE) and component testing, epitope-sIgE assays, and basophil activation testing. Predicting reaction severity with serologic testing is challenged by a range of co-factors that influence reaction severity, such as the amount and form of any allergen consumed and comorbid disease. In 2020, the Allergy Immunology Joint Task Force on Practice Parameters recommended Ara h 2-sIgE as the most cost-effective diagnostic test for peanut allergy because of its superior performance, when compared with skin prick testing and serum IgE. Basophil activation testing, a functional test of allergic response not evaluated in the Joint Task Force on Practice Parameters guideline, is a promising option for both allergy diagnosis and prognosis. Similarly, epitope-sIgE testing may improve prediction of reaction thresholds, but further validation is needed. Despite advances in food allergy testing, many of these tools remain limited by cost, accessibility, and feasibility. In addition, there is a need for further research on how atopic dermatitis may be modifying serologic food allergy severity assessments. Given these limitations, allergy test selection requires a shared decision-making approach so that a patient's values and preferences regarding financial impact, inconvenience, and psychological effects are considered in the context of clinician expertise on the timing and use of optimized testing.
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Affiliation(s)
| | - David B K Golden
- Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Helen A Brough
- Department of Women and Children's Health (Pediatric Allergy), School of Life Courses Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service and Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, United Kingdom
| | - Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Courses Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service and Children's Allergy Service, Evelina Children's Hospital, Guy's and St. Thomas's NHS Foundation Trust, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Marcus S Shaker
- Dartmouth Geisel School of Medicine, Hanover, New Hampshire; Section of Allergy and Immunology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.
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4
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Jessen FB, Mortz CG, Eller E, Gudichsen JH, Baekdal EA, Bindslev-Jensen C. A comparison of double-blind, placebo-controlled food challenge and open food challenge. Allergy 2023; 78:3204-3211. [PMID: 37539617 DOI: 10.1111/all.15834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 06/12/2023] [Accepted: 06/23/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Double-blind, placebo-controlled food challenge (DBPCFC) remains the gold standard for diagnosing food allergy, despite sparse comparisons to open food challenges (OpenFCs). The objective of this retrospective study was to compare severity of symptoms and threshold values (cumulative dose of food allergen eliciting a clinical reaction) in children and adults with peanut allergy, challenged in an open and/or double-blind, placebo-controlled protocol. METHODS This study included patients from the Allergy Centre, Odense University Hospital with a positive oral food challenge, defined as strict objective signs, with peanut during the period 2001-2022. Severity of symptoms was graded using the Sampson's severity score. Distribution models of threshold values were calculated using log-normal interval-censored survival analysis, and the number of placebo reactions was evaluated. RESULTS In total, 318 positive OpenFCs and 86 DBPCFCs were included. There was no difference in severity of symptoms nor threshold values comparing the two challenge types, neither when stratified for age groups. However, a higher proportion of children experienced Grade 3 symptoms in the double-blind group. Only one patient had a positive reaction to a placebo challenge. CONCLUSION Our findings do not advocate for DBPCFC being superior to OpenFC, if the latter is performed with strict objective stop criteria by trained staff.
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Affiliation(s)
- Frederik Bloch Jessen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Charlotte G Mortz
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Esben Eller
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Julie H Gudichsen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Emil A Baekdal
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
| | - Carsten Bindslev-Jensen
- Department of Dermatology and Allergy Centre, Odense Research Center for Anaphylaxis (ORCA), Odense University Hospital, Odense, Denmark
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Dribin TE, Waserman S, Turner PJ. Who Needs Epinephrine? Anaphylaxis, Autoinjectors, and Parachutes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1036-1046. [PMID: 36796511 DOI: 10.1016/j.jaip.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 02/07/2023] [Accepted: 02/07/2023] [Indexed: 02/16/2023]
Abstract
International guidelines stipulate that intramuscular (IM) epinephrine (adrenaline) is the first-line treatment for anaphylaxis, with an established good safety profile. The availability of epinephrine autoinjectors (EAI) has greatly facilitated the lay administration of IM epinephrine in community settings. However, key areas of uncertainty remain around epinephrine usage. These include variations in prescribing EAI, what symptoms should prompt epinephrine administration, whether emergency medical services (EMS) need to be contacted after administration, and whether epinephrine administered via EAI reduces mortality from anaphylaxis or improves quality of life measures. We provide a balanced commentary on these issues. There is increasing recognition that a poor response to epinephrine, particularly after 2 doses, is a useful marker of severity and the need for urgent escalation. It is likely that patients who respond to a single epinephrine dose do not require EMS activation or emergency department transfer, but data are needed to demonstrate the safety of this approach. Lastly, patients at risk of anaphylaxis must be counseled against over-reliance on EAI alone.
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Affiliation(s)
- Timothy E Dribin
- Division of Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Susan Waserman
- Division of Clinical Immunology and Allergy, Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul J Turner
- National Heart & Lung Institute, Imperial College London, London, United Kingdom.
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6
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La Vieille S, Hourihane JO, Baumert JL. Precautionary Allergen Labeling: What Advice Is Available for Health Care Professionals, Allergists, and Allergic Consumers? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:977-985. [PMID: 36682535 DOI: 10.1016/j.jaip.2022.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 12/12/2022] [Accepted: 12/20/2022] [Indexed: 01/21/2023]
Abstract
In most countries, the use of precautionary allergen labeling (PAL) is not governed by regulation. PAL was initially identified as a judicious risk management measure to address instances of "unavoidable" cross-contact with priority food allergens during food processing. However, PAL has gradually been devalued in part due to overuse and inconsistent application by the food industry. Currently, most food products do not contain detectable allergen residue or contain only low concentrations of residue of the allergens declared using PAL; however, occasionally, high concentrations of allergen residue are reported, rendering it an ineffective risk communication tool for allergic consumers. In this context, several reasons exist that make the consumption of products bearing a PAL statement not advisable for people with food allergies. The main reason is that the risk is generally not correlated with the statement used by manufacturers. Because of the increased use of PAL on prepackaged food products, and to maximize food choices for allergic individuals, health care professionals increasingly advise some patients considered to be "not highly allergic" to consume products bearing a PAL statement. This article explains why the consumption of products with PAL is not advisable without having a full clinical evaluation and knowledge that an allergen risk assessment has been conducted. It also discusses the perspectives for a better use of PAL on the basis of the recent Food and Agricultural Organization/World Health Organization recommendations on food allergens.
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Affiliation(s)
- Sébastien La Vieille
- Food Directorate, Health Canada, Ottawa, ON, Canada; Food Science Department, Laval University, Québec, QC, Canada.
| | | | - Joseph L Baumert
- Food Allergy Research and Resource Program, Department of Food Science and Technology, University of Nebraska, Lincoln, Neb
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7
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Turner PJ, Arasi S, Ballmer‐Weber B, Baseggio Conrado A, Deschildre A, Gerdts J, Halken S, Muraro A, Patel N, Van Ree R, de Silva D, Worm M, Zuberbier T, Roberts G. Risk factors for severe reactions in food allergy: Rapid evidence review with meta-analysis. Allergy 2022; 77:2634-2652. [PMID: 35441718 PMCID: PMC9544052 DOI: 10.1111/all.15318] [Citation(s) in RCA: 41] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Revised: 04/04/2022] [Accepted: 04/17/2022] [Indexed: 02/06/2023]
Abstract
This rapid review summarizes the most up to date evidence about the risk factors for severe food-induced allergic reactions. We searched three bibliographic databases for studies published between January 2010 and August 2021. We included 88 studies and synthesized the evidence narratively, undertaking meta-analysis where appropriate. Significant uncertainties remain with respect to the prediction of severe reactions, both anaphylaxis and/or severe anaphylaxis refractory to treatment. Prior anaphylaxis, an asthma diagnosis, IgE sensitization or basophil activation tests are not good predictors. Some molecular allergology markers may be helpful. Hospital presentations for anaphylaxis are highest in young children, yet this age group appears at lower risk of severe outcomes. Risk of severe outcomes is greatest in adolescence and young adulthood, but the contribution of risk taking behaviour in contributing to severe outcomes is unclear. Evidence for an impact of cofactors on severity is lacking, although food-dependent exercise-induced anaphylaxis may be an exception. Some medications such as beta-blockers or ACE inhibitors may increase severity, but appear less important than age as a factor in life-threatening reactions. The relationship between dose of exposure and severity is unclear. Delays in symptom recognition and anaphylaxis treatment have been associated with more severe outcomes. An absence of prior anaphylaxis does not exclude its future risk.
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Affiliation(s)
- Paul J. Turner
- National Heart & Lung InstituteImperial College LondonLondonUK
| | - Stefania Arasi
- Translational Research in Paediatric Specialities AreaDivision of AllergyBambino Gesù Children's HospitalIRCCSRomeItaly
| | - Barbara Ballmer‐Weber
- Clinic for Dermatology and AllergologyKantonsspital St. GallenSt. GallenSwitzerland,Department of DermatologyUniversity Hospital ZürichZürichSwitzerland
| | | | - Antoine Deschildre
- CHU Lille, Univ. LillePediatric Pulmonology and Allergy DepartmentHôpital Jeanne de FlandreLilleFrance
| | | | - Susanne Halken
- Hans Christian Andersen Children’s HospitalOdense University HospitalOdenseDenmark
| | | | - Nandinee Patel
- National Heart & Lung InstituteImperial College LondonLondonUK
| | - Ronald Van Ree
- Departments of Experimental Immunology and of OtorhinolaryngologyAmsterdam University Medical Centers, location AMCAmsterdamThe Netherlands
| | | | - Margitta Worm
- Division of Allergy and ImmunologyDepartment of Dermatology, Venerology and AllergyCharité, Universitätsmedizin BerlinBerlinGermany
| | - Torsten Zuberbier
- Division of Allergy and ImmunologyDepartment of Dermatology, Venerology and AllergyCharité, Universitätsmedizin BerlinBerlinGermany
| | - Graham Roberts
- NIHR Southampton Biomedical Research CentreUniversity Hospital Southampton NHS Foundation TrustFaculty of MedicineUniversity of SouthamptonSouthamptonUK,The David Hide Asthma and Allergy Research CentreSt Mary's HospitalIsle of WightUK
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8
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Fernández‐Rivas M, Gómez García I, Gonzalo‐Fernández A, Fuentes Ferrer M, Dölle‐Bierke S, Marco‐Martín G, Ballmer‐Weber BK, Asero R, Belohlavkova S, Beyer K, de Blay F, Clausen M, Datema MR, Dubakiene R, Grimshaw KEC, Hoffmann‐Sommergruber K, Hourihane JO, Jedrzejczak‐Czechowicz M, Knulst AC, Kralimarkova T, Le T, Papadopoulos NG, Popov TA, Poulsen LK, Purohit A, Seneviratne SL, Simpson A, Sinaniotis A, Turkalji M, Vázquez‐Cortés S, Vera‐Berrios RN, Muraro A, Worm M, Roberts G, van Ree R, Fernández‐Pérez C, Turner PJ, Mills ENC. Development and validation of the food allergy severity score. Allergy 2022; 77:1545-1558. [PMID: 34716996 PMCID: PMC9298738 DOI: 10.1111/all.15165] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 10/10/2021] [Indexed: 10/27/2022]
Abstract
BACKGROUND The heterogeneity and lack of validation of existing severity scores for food allergic reactions limit standardization of case management and research advances. We aimed to develop and validate a severity score for food allergic reactions. METHODS Following a multidisciplinary experts consensus, it was decided to develop a food allergy severity score (FASS) with ordinal (oFASS) and numerical (nFASS) formats. oFASS with 3 and 5 grades were generated through expert consensus, and nFASS by mathematical modeling. Evaluation was performed in the EuroPrevall outpatient clinic cohort (8232 food reactions) by logistic regression with request of emergency care and medications used as outcomes. Discrimination, classification, and calibration were calculated. Bootstrapping internal validation was followed by external validation (logistic regression) in 5 cohorts (3622 food reactions). Correlation of nFASS with the severity classification done by expert allergy clinicians by Best-Worst Scaling of 32 food reactions was calculated. RESULTS oFASS and nFASS map consistently, with nFASS having greater granularity. With the outcomes emergency care, adrenaline and critical medical treatment, oFASS and nFASS had a good discrimination (receiver operating characteristic area under the curve [ROC-AUC]>0.80), classification (sensitivity 0.87-0.92, specificity 0.73-0.78), and calibration. Bootstrapping over ROC-AUC showed negligible biases (1.0 × 10-6 -1.23 × 10-3 ). In external validation, nFASS performed best with higher ROC-AUC. nFASS was strongly correlated (R 0.89) to best-worst scoring of 334 expert clinicians. CONCLUSION FASS is a validated and reliable method to measure severity of food allergic reactions. The ordinal and numerical versions that map onto each other are suitable for use by different stakeholders in different settings.
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Affiliation(s)
- Montserrat Fernández‐Rivas
- Allergy DepartmentHospital Clínico San CarlosFacultad de MedicinaUniversidad Complutense (UCM)IdISSC, ARADyALMadridSpain
| | | | | | - Manuel Fuentes Ferrer
- Unidad de Apoyo a la InvestigaciónPreventive Medicine DepartmentHospital Clínico San CarlosIdISSCUniversidad Alfonso X El SabioMadridSpain
| | - Sabine Dölle‐Bierke
- Division of Allergy and ImmunologyDepartment of Dermatology, Venerology and AllergologyCharité—Universitätsmedizin BerlinCorporate Member of Freie Universität BerlinHumboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | | | - Barbara K. Ballmer‐Weber
- Department of DermatologyUniversity Hospital ZurichZurichSwitzerland,Clinic for Dermatology and AllergologyKantonsspital St GallenSt GallenSwitzerland
| | - Riccardo Asero
- Ambulatorio di AllergologiaClinica San CarloPaderno Dugnano, MilanItaly
| | | | - Kirsten Beyer
- Department of Pediatric Respiratory Medicine, Immunology and Intensive Care MedicineCharité Universitätsmedizin BerlinBerlinGermany
| | - Frédéric de Blay
- Chest Diseases DepartmentStrasbourg University HospitalFederation of Translational MedicineUniversity of StrasbourgStrasbourgFrance
| | - Michael Clausen
- Children's Hospital and Department of AllergyLandspitali University HospitalReykjavikIceland
| | - Mareen R. Datema
- Department of Experimental Immunology, and Department of Clinical Epidemiology, Biostatistics and BioinformaticsAmsterdam University Medical CenterAmsterdamThe Netherlands
| | | | - Kate E. C. Grimshaw
- Department of DieteticsSalford Royal NHS Foundation TrustSalfordUK,Clinical and Experimental SciencesFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | | | - Jonathan O’B Hourihane
- Royal College of Surgeons in IrelandChildren's Health Ireland at Temple StreetDublinIreland
| | | | - André C. Knulst
- Dept. Dermatology/AllergologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | | | - Thuy‐My Le
- Dept. Dermatology/AllergologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtThe Netherlands
| | - Nikolaos G. Papadopoulos
- Allergy Dpt, 2nd Pediatric clinicUniversity of AthensAthensGreece,Division of InfectionImmunity & Respiratory MedicineUniversity of ManchesterManchesterUK
| | | | - Lars K. Poulsen
- Allergy ClinicCopenhagen University Hospital at Herlev‐GentofteCopenhagenDenmark
| | - Ashok Purohit
- Allergy DivisionChest Disease DepartmentUniversity Hospital of StrasbourgStrasbourgFrance
| | - Suranjith L. Seneviratne
- Department of Clinical Immunology and AllergyCentral Manchester and Manchester Children's University Hospitals NHS TrustManchesterUK,Institute of Immunity and TransplantationRoyal Free Hospital and University College LondonLondonUK
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory MedicineSchool of Biological SciencesManchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, and Manchester University NHS Foundation TrustThe University of ManchesterManchesterUK
| | - Atanasios Sinaniotis
- Allergy Department2nd Pediatric ClinicUniversity of AthensAthensGreece,Allergy DepartmentSotiria Chest Diseases HospitalAthensGreece
| | - Mirjana Turkalji
- Srebrnjak Children's Hospital ZagrebCatholic University of Croatia Zagreb, and Medical Faculty OsijekJ.J.Strossmayer UniversityOsijekCroatia
| | | | | | - Antonella Muraro
- Food Allergy Referral Centre Veneto RegionDepartment of Women and Child HealthPadua General University HospitalPaduaItaly
| | - Margitta Worm
- Division of Allergy and ImmunologyDepartment of Dermatology, Venerology and AllergologyCharité—Universitätsmedizin BerlinCorporate Member of Freie Universität BerlinHumboldt‐Universität zu Berlin, and Berlin Institute of HealthBerlinGermany
| | - Graham Roberts
- NIHR Southampton Biomedical Research CentreUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK,Clinical and Experimental Sciences and Human Development in HealthFaculty of MedicineUniversity of SouthamptonSouthamptonUK,The David Hide Asthma and Allergy Research CentreSt Mary's HospitalIsle of WightUK
| | - Ronald van Ree
- Departments of Experimental Immunology and of OtorhinoraryngologyAmsterdam University Medical CentersAmsterdamThe Netherlands
| | - Cristina Fernández‐Pérez
- Preventive Medicine DepartmentHospital Clínico San CarlosIdISSCMadridSpain,Preventive Medicine DepartmentComplejo Hospitalario Universitario Santiago de CompostelaSantiago de CompostelaSpain
| | - Paul J. Turner
- National Heart & Lung InstituteImperial College LondonLondonUK
| | - Elizabeth N. Clare Mills
- Division of Infection, Immunity and Respiratory MedicineManchester Academic Health Sciences CentreManchester Institute of BiotechnologyUniversity of ManchesterManchesterUK
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9
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Dietary Linolenic Acid Increases Sensitizing and Eliciting Capacities of Cow's Milk Whey Proteins in BALB/c Mice. Nutrients 2022; 14:nu14040822. [PMID: 35215473 PMCID: PMC8877816 DOI: 10.3390/nu14040822] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 02/11/2022] [Accepted: 02/13/2022] [Indexed: 02/01/2023] Open
Abstract
α-Lactalbumin (BLA) and β-lactoglobulin (BLG) are the major whey proteins causing allergic reactions. Polyunsaturated fatty acids (PUFAs) stand among the extrinsic factors of the food matrix that can bind BLA and BLG and change their bioactivities, but their contribution to change the allergenic properties of these proteins has not been investigated. Here, we aimed to determine how PUFAs influence BLA and BLG to sensitize and trigger allergic responses in BALB/c mice. First, tricine-SDS-PAGE and spectroscopic assays identified that α-linolenic acid (ALA, as a proof-of-concept model) can induce BLA and BLG to form cross-linked complexes and substantially modify their conformation. Then, BALB/c mice (n = 10/group) were orally sensitized and challenged with BLA and BLG or ALA-interacted BLA and BLG, respectively. Allergic reactions upon oral challenge were determined by measuring clinical allergic signs, specific antibodies, levels of type-1/2 cytokines, the status of mast cell activation, and percentage of cell populations (B and T cells) in different tissues (PP, MLN, and spleen). Overall, systemic allergic reaction was promoted in mice gavage with ALA-interacted BLA and BLG by disrupting the Th1/Th2 balance toward a Th2 immune response with the decreased number of Tregs. Enhanced induction of Th2-related cytokines, as well as serum-specific antibodies and mast cell activation, was also observed. In this study, we validated that ALA in the food matrix promoted both the sensitization and elicitation of allergic reactions in BALB/c mice.
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10
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Peanut Can Be Used as a Reference Allergen for Hazard Characterization in Food Allergen Risk Management: A Rapid Evidence Assessment and Meta-Analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 10:59-70. [PMID: 34438104 PMCID: PMC8790324 DOI: 10.1016/j.jaip.2021.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 12/03/2022]
Abstract
Regional and national legislation mandates the disclosure of “priority” allergens when present as an ingredient in foods, but this does not extend to the unintended presence of allergens due to shared production facilities. This has resulted in a proliferation of precautionary allergen (“may contain”) labels (PAL) that are frequently ignored by food-allergic consumers. Attempts have been made to improve allergen risk management to better inform the use of PAL, but a lack of consensus has led to variety of regulatory approaches and nonuniformity in the use of PAL by food businesses. One potential solution would be to establish internationally agreed “reference doses,” below which no PAL would be needed. However, if reference doses are to be used to inform the need for PAL, then it is essential to characterize the hazard associated with these low-level exposures. For peanut, there are now published data relating to over 3000 double-blind, placebo-controlled challenges in allergic individuals, but a similar level of evidence is lacking for other priority allergens. We present the results of a rapid evidence assessment and meta-analysis for the risk of anaphylaxis to a low-level allergen exposure for priority allergens. On the basis of this analysis, we propose that peanut can and should be considered an exemplar allergen for the hazard characterization at a low-level allergen exposure.
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11
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Patel N, Adelman DC, Anagnostou K, Baumert JL, Blom WM, Campbell DE, Chinthrajah RS, Mills ENC, Javed B, Purington N, Remington BC, Sampson HA, Smith AD, Yarham RAR, Turner PJ. Using data from food challenges to inform management of consumers with food allergy: A systematic review with individual participant data meta-analysis. J Allergy Clin Immunol 2021; 147:2249-2262.e7. [PMID: 33571537 PMCID: PMC8168954 DOI: 10.1016/j.jaci.2021.01.025] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/10/2021] [Accepted: 01/27/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Eliciting doses (EDs) (eg, ED01 or ED05 values, which are the amounts of allergen expected to cause objective symptoms in 1% and 5% of the population with an allergy, respectively) are increasingly being used to inform allergen labeling and clinical management. These values are generated from food challenge, but the frequency of anaphylaxis in response to these low levels of allergen exposure and their reproducibility are unknown. OBJECTIVE Our aim was to determine (1) the rate of anaphylaxis in response to low-level peanut exposure and (2) the reproducibility of reaction thresholds (and anaphylaxis) at food challenge. METHODS We conducted a systematic review and individual participant data meta-analysis of studies that reported at least 50 individuals with peanut allergy reacting to peanut at double-blind, placebo-controlled food challenge (DBPCFC) and were published between January 2010 and September 2020. Risk of bias was assessed by using National Institute for Clinical Excellence methodologic checklists. RESULTS A total of 19 studies were included (covering a total of 3151 participants, 534 of whom subsequently underwent further peanut challenge). At individual participant data meta-analysis, 4.5% (95% CI, 1.9% to 10.1%) of individuals reacted to 5 mg or less of peanut protein with anaphylaxis (moderate heterogeneity [I2 = 57%]). Intraindividual thresholds varied by up to 3 logs, although this variation was limited to a half-log change in 71.2% (95% CI, 56.2% to 82.6%) of individuals. In all, 2.4% (95% CI, 1.1% to 5.0%) of patients initially tolerated 5 mg of peanut protein but then reacted to this dose at subsequent challenge (low heterogeneity [I2 = 16%]); none developed anaphylaxis. CONCLUSION Around 5% of individuals reacting to an ED01 or ED05 level of exposure to peanut might develop anaphylaxis in response to that dose. This equates to 1 and 6 anaphylaxis events per 2500 patients exposed to an ED01 or ED05 dose, respectively, in the broader population of individuals with peanut allergy.
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Affiliation(s)
- Nandinee Patel
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | | | - Katherine Anagnostou
- Section of Allergy and Immunology, Baylor College of Medicine, Houston, Tex; Section of Allergy and Immunology, Department of Pediatrics, Texas Children's Hospital, Houston, Tex
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, Neb
| | - W Marty Blom
- The Netherlands Organisation of Applied Scientific Research, Utrecht, The Netherlands
| | - Dianne E Campbell
- Department of Allergy and Immunology, The Children's Hospital at Westmead, Sydney, Australia; DBV Technologies, Montrouge, France
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research, Stanford, Calif; Division of Pulmonary, Allergy, and Critical Care Medicine, Stanford University, Stanford, Calif
| | - E N Clare Mills
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Bushra Javed
- Division of Infection, Immunity and Respiratory Medicine, Manchester Institute of Biotechnology, University of Manchester, Manchester, United Kingdom
| | - Natasha Purington
- Department of Medicine, Quantitative Sciences Unit, Stanford University School of Medicine, Stanford, Calif
| | - Benjamin C Remington
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, Neb
| | - Hugh A Sampson
- DBV Technologies, Montrouge, France; Division of Pediatric Allergy and Immunology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - Paul J Turner
- National Heart and Lung Institute, Imperial College London, London, United Kingdom.
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12
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Eigenmann PA, Ebisawa M, Greenhawt M, Hourihane JO, Perry TT, Remington BC, Wood RA. Addressing risk management difficulties in children with food allergies. Pediatr Allergy Immunol 2021; 32:658-666. [PMID: 33480057 DOI: 10.1111/pai.13455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 10/19/2020] [Accepted: 10/26/2020] [Indexed: 12/25/2022]
Abstract
Risk is a concept inherent in every medical procedure. It can be defined as the probability of an adverse event in a defined population over a specified period of time. In the frame of food allergy management, it might be related to a diagnostic procedure, a treatment, or the consumption of foods. The risk of an adverse event can also be augmented by individual factors. This rostrum article discusses various aspects faced by children with food allergies in the light of risk, and their practical implications. Identifying personal risks for severe reaction, such as unstable asthma, and correcting them whenever possible also contribute to a reduction of the risk inherent to food allergy. Among the facets discussed, oral food challenges (OFC) are the most common diagnostic procedures implying an inherent risk. The risk of OFCs can be minimized by correct indication and timing of the test, a safe setting, as well as by ensuring that the patient is otherwise well without potential stressor potentially increasing the risk of a more severe reaction. Oral immunotherapy (OIT) has been studied as a potential treatment for increasing the threshold dose for reaction, and thus reducing the risk of accidental reaction. Nevertheless, the procedure is not devoid of risk as the patients may and do often react during the course of the procedure. Ingestion of trace amounts in processed foods, mainly in community settings such as restaurants, schools, or day care, represents a potential risk of reactions, although for a minority of patients. Precautionary allergen labeling (PAL) is a widespread strategy to reduce the potential risk of reactions due to traces. However, PAL is currently inefficient due to inconsistent labeling, also not indicating a clear maximum amount possibly present in the manufactured food. Finally, cost-effectiveness needs to be considered in risk management, as many risk reduction procedures are clearly not cost-effective.
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Affiliation(s)
- Philippe A Eigenmann
- Pediatric Allergy Unit, Department of Woman, Child and Adolescent, University Hospitals of Geneva, Geneva, Switzerland
| | - Motohiro Ebisawa
- Clinical Research Center for Allergy and Rheumatology, National Hospital Organization Sagamihara National Hospital, Sagamihara, Japan
| | - Matthew Greenhawt
- Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jonathan O'B Hourihane
- Paediatrics and Child Health, Royal College of Surgeons in Ireland, Children's Health Ireland, Temple St Hospital, Dublin, Ireland
| | - Tamara T Perry
- University of Arkansas for Medical Sciences and Arkansas Children's Research Institute, Little Rock, AR, USA
| | - Benjamin C Remington
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, NE, USA.,Remington Consulting Group BV, Utrecht, The Netherlands
| | - Robert A Wood
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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13
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Haber LT, Reichard JF, Henning AK, Dawson P, Chinthrajah RS, Sindher SB, Long A, Vincent MJ, Nadeau KC, Allen BC. Bayesian hierarchical evaluation of dose-response for peanut allergy in clinical trial screening. Food Chem Toxicol 2021; 151:112125. [PMID: 33722597 DOI: 10.1016/j.fct.2021.112125] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/24/2021] [Accepted: 03/09/2021] [Indexed: 01/01/2023]
Abstract
Risk-based labeling based on the minimal eliciting doses (EDs) in sensitized populations is a potential replacement for precautionary allergen labeling of food allergens. We estimated the dose-response distribution for peanut allergen using data from double-blind placebo-controlled food challenges (DBPCFCs) conducted in the US at multiple sites, testing a population believed to be similar to the general U.S. food allergic population. Our final (placebo-adjusted) dataset included 548 challenges of 481 subjects. Bayesian hierarchical analysis facilitated model fitting, and accounted for variability associated with various levels of data organization. The data are best described using a complex hierarchical structure that accounts for inter-individual variability and variability across study locations or substudies. Bayesian model averaging could simultaneously consider the fit of multiple models, but the Weibull model dominated so strongly that model averaging was not needed. The ED01 and ED05 (and 95% credible intervals) are 0.052 (0.021, 0.13) and 0.49 (0.22, 0.97) mg peanut protein, respectively. Accounting for challenges with severe reactions at the LOAEL, by using the dose prior to the LOAEL as the new LOAEL, the ED01 drops to 0.029 (0.014, 0.074) mg peanut protein. Our results could aid in establishing improved food labeling guidelines in the management of food allergies.
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Affiliation(s)
- Lynne T Haber
- University of Cincinnati, Department of Environmental and Public Health Sciences, 160 Panzeca Way, Cincinnati, OH, 45267, USA.
| | - John F Reichard
- University of Cincinnati, Department of Environmental and Public Health Sciences, 160 Panzeca Way, Cincinnati, OH, 45267, USA
| | - Alice K Henning
- The Emmes Company, LLC, 401 North Washington St., Suite 700, Rockville, MD, 20850, USA
| | - Peter Dawson
- The Emmes Company, LLC, 401 North Washington St., Suite 700, Rockville, MD, 20850, USA
| | - R Sharon Chinthrajah
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Sayantani B Sindher
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Andrew Long
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Melissa J Vincent
- University of Cincinnati, Department of Environmental and Public Health Sciences, 160 Panzeca Way, Cincinnati, OH, 45267, USA
| | - Kari C Nadeau
- Sean N. Parker Center for Allergy and Asthma Research at Stanford University and Division of Pulmonary, Allergy, & Critical Care Medicine, Department of Medicine, Stanford, CA, USA
| | - Bruce C Allen
- Independent Consultant, 101 Corbin Hill Circle, Chapel Hill, NC, 27514, USA
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14
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A Food, a Bite, a Sip: How Much Allergen Is in That? Nutrients 2021; 13:nu13020587. [PMID: 33578927 PMCID: PMC7916672 DOI: 10.3390/nu13020587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/28/2021] [Accepted: 02/02/2021] [Indexed: 11/17/2022] Open
Abstract
Detailed information about the amount of allergenic protein ingested by the patient prior to an allergic reaction yields valuable information for the diagnosis, guidance and management of food allergy. However, the exact amount of ingredients is often not declared on the label. In this study the feasibility was studied for estimating the amount of allergenic protein from milk, eggs, peanuts and hazelnuts in frequently consumed composite and non-composite foods and per bite or sip size in different age groups in the Netherlands. Foods containing milk, egg, peanut or hazelnut most frequently consumed were selected for the age groups 2–3, 4–6 and 19–30 years. If the label did not yield clear information, the amount of allergenic protein was estimated based on food labels. Bite or sip sizes were determined in these age groups in 30 different foods. The amount of allergenic protein could be estimated in 47/70 (67%) of composite foods, which was complex. Estimated protein content of milk, egg, peanut and hazelnut was 2–3 g for most foods but varied greatly from 3 to 8610 mg and may be below threshold levels of the patient. In contrast, a single bite or sip can contain a sufficient amount of allergenic protein to elicit an allergic reaction. Bite and sip sizes increased with age. In every day practice it is hard to obtain detailed and reliable information about the amount of allergenic protein incorporated in composite foods. We encourage companies to disclose the amount of common allergenic foods on their labels.
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15
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Can we define a level of protection for allergic consumers that everyone can accept? Regul Toxicol Pharmacol 2020; 117:104751. [PMID: 32763252 DOI: 10.1016/j.yrtph.2020.104751] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 07/23/2020] [Accepted: 07/27/2020] [Indexed: 01/01/2023]
Abstract
Substantial progress has been made in characterising the risk associated with exposure to allergens in food. However, absence of agreement on what risk is tolerable has made it difficult to set quantitative limits to manage that risk and protect allergic consumers effectively. This paper reviews scientific progress in the area and the diverse status of allergen management approaches and lack of common standards across different jurisdictions, including within the EU. This lack of regulation largely explains why allergic consumers find Precautionary Allergen Labelling confusing and cannot rely on it. We reviewed approaches to setting quantitative limits for a broad range of food safety hazards to identify the reasoning leading to their adoption. This revealed a diversity of approaches from pragmatic to risk-based, but we could not find clear evidence of the process leading to the decision on risk acceptability. We propose a framework built around the criteria suggested by Murphy and Gardoni (2008) for approaches to defining tolerable risks. Applying these criteria to food allergy, we concluded that sufficient knowledge exists to implement the framework, including sufficient expertise across the whole range of stakeholders to allow opinions to be heard and respected, and a consensus to be achieved.
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16
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Graham F, Caubet JC, Eigenmann PA. Can my child with IgE-mediated peanut allergy introduce foods labeled with "may contain traces"? Pediatr Allergy Immunol 2020; 31:601-607. [PMID: 32160355 DOI: 10.1111/pai.13244] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 02/16/2020] [Accepted: 02/25/2020] [Indexed: 01/19/2023]
Abstract
Peanut IgE-mediated food allergy is one of the most common food allergies in children with a prevalence that has increased in the past decades in Westernized countries. Peanut allergies can trigger severe reactions and usually persist over time. Peanut-allergic children and their families are often confronted to processed foods with precautionary allergen labeling (PAL) such as "may contain traces of peanuts," which are frequently used by the food industry. Patients are generally confused as to whether eating such foods entails a risk of allergic reaction, which can ultimately lead to dietary restrictions and decreased quality of life. Thus, guidance toward eviction of foods with PALs such as "may contain traces of peanuts" is a recurring problem that peanut-allergic patients address during pediatric allergy consultations with varying attitudes among allergists. Many studies have evaluated peanut contamination in foods with PALs, with generally less than 10% of foods containing detectable levels of peanuts, albeit heterogeneous amounts, with in rare occasions levels that could trigger allergic reactions in certain patients. The risk of reacting to foods with traces varies significantly with threshold, with patients with the lowest reaction thresholds at highest risk, and a dramatic reduction of risk as threshold increases. Thus, risk stratification based on individual reaction threshold may help stratify patients' risk of reacting to foods with PAL. In clinical practice, a single-dose 30 mg peanut protein oral food challenge may be an option to stratify peanut-allergic patients' risk when introducing foods with PAL, as illustrated by three clinical cases.
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Affiliation(s)
- François Graham
- Pediatric Allergy Unit, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland.,Department of Allergy and Immunology, Centre Hospitalier Universitaire Sainte-Justine and Centre Hospitalier de l'Université de Montréal, Montreal, QC, Canada
| | - Jean-Christoph Caubet
- Pediatric Allergy Unit, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
| | - Philippe A Eigenmann
- Pediatric Allergy Unit, University Hospitals of Geneva, University of Geneva, Geneva, Switzerland
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17
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Santos AF, Du Toit G, O'Rourke C, Becares N, Couto-Francisco N, Radulovic S, Khaleva E, Basting M, Harris KM, Larson D, Sayre P, Plaut M, Roberts G, Bahnson HT, Lack G. Biomarkers of severity and threshold of allergic reactions during oral peanut challenges. J Allergy Clin Immunol 2020; 146:344-355. [PMID: 32311390 PMCID: PMC7417812 DOI: 10.1016/j.jaci.2020.03.035] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 02/10/2020] [Accepted: 03/20/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Oral food challenge (OFC) is the criterion standard to assess peanut allergy (PA), but it involves a risk of allergic reactions of unpredictable severity. OBJECTIVE Our aim was to identify biomarkers for risk of severe reactions or low dose threshold during OFC to peanut. METHODS We assessed Learning Early about Peanut Allergy study, Persistance of Oral Tolerance to Peanut study, and Peanut Allergy Sensitization study participants by administering the basophil activation test (BAT) and the skin prick test (SPT) and measuring the levels of peanut-specific IgE, Arachis hypogaea 2-specific IgE, and peanut-specific IgG4, and we analyzed the utility of the different biomarkers in relation to PA status, severity, and threshold dose of allergic reactions to peanut during OFC. RESULTS When a previously defined optimal cutoff was used, the BAT diagnosed PA with 98% specificity and 75% sensitivity. The BAT identified severe reactions with 97% specificity and 100% sensitivity. The SPT, level of Arachis hypogaea 2-specific IgE, level of peanut-specific IgE, and IgG4/IgE ratio also had 100% sensitivity but slightly lower specificity (92%, 93%, 90%, and 88%, respectively) to predict severity. Participants with lower thresholds of reactivity had higher basophil activation to peanut in vitro. The SPT and the BAT were the best individual predictors of threshold. Multivariate models were superior to individual biomarkers and were used to generate nomograms to calculate the probability of serious adverse events during OFC for individual patients. CONCLUSIONS The BAT diagnosed PA with high specificity and identified severe reactors and low threshold with high specificity and high sensitivity. The BAT was the best biomarker for severity, surpassed only by the SPT in predicting threshold. Nomograms can help estimate the likelihood of severe reactions and reactions to a low dose of allergen in individual patients with PA.
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Affiliation(s)
- Alexandra F Santos
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
| | - George Du Toit
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Colin O'Rourke
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Wash
| | - Natalia Becares
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Natália Couto-Francisco
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom
| | - Suzana Radulovic
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Ekaterina Khaleva
- Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Monica Basting
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom
| | | | | | - Peter Sayre
- Division of Hematology-Oncology, Department of Medicine, University of California, San Francisco, Calif
| | - Marshall Plaut
- National Institute of Allergy and Infectious Diseases, Bethesda, Md
| | - Graham Roberts
- David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, Southampton, United Kingdom; National Institute for Health Research Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and Clinical and Experimental Sciences Academic Unit, University of Southampton Faculty of Medicine, Southampton, United Kingdom
| | - Henry T Bahnson
- Immune Tolerance Network, Benaroya Research Institute, Seattle, Wash
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, London, United Kingdom; Peter Gorer Department of Immunobiology, School of Immunology and Microbial Sciences, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom; Asthma UK Centre in Allergic Mechanisms of Asthma, London, United Kingdom.
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18
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Fukuie T, Nishiura H, Miyaji Y, Matsumoto K, Ohya Y, Saito H. Effect of specific IgE on eliciting dose in children with cow's milk allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:3660-3662.e2. [PMID: 32679350 DOI: 10.1016/j.jaip.2020.06.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/06/2020] [Accepted: 06/27/2020] [Indexed: 11/17/2022]
Affiliation(s)
- Tatsuki Fukuie
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan.
| | - Hiroshi Nishiura
- Department of Hygiene, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Yumiko Miyaji
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kenji Matsumoto
- Department of Allergy and Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Yukihiro Ohya
- Allergy Center, National Center for Child Health and Development, Tokyo, Japan
| | - Hirohisa Saito
- Department of Allergy and Immunology, National Research Institute for Child Health and Development, Tokyo, Japan
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19
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Budi HS, Pebriani I. The Protein Level and Molecular Weight Analysis in Different Children's Toothpaste, which Probably Induced Hypersensitivity. Contemp Clin Dent 2020; 11:245-248. [PMID: 33776350 PMCID: PMC7989753 DOI: 10.4103/ccd.ccd_394_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 04/16/2020] [Accepted: 05/29/2020] [Indexed: 11/04/2022] Open
Abstract
CONTEXT A new case of an allergic reaction due to the use of toothpaste was found in California, United States, causing the death of an 11-year-old girl. Ingredients contained in toothpaste suspected as a cause of allergies are milk protein compounds. AIMS The aim is to compare the protein level and molecular weight in children's toothpaste. SETTINGS AND DESIGN Stratified random sampling. SUBJECTS AND METHODS Samples used were children's toothpaste products in society, namely, Pepsodent®, Cussons®, Enzyme®, Kodomo®, Formula®, Colgate®, the toothpaste contain recaldent of GC Tooth Moose® and pure cow's milk. Those samples were divided into eight groups, randomly selected according to the purpose (stratified random sampling), and then coded to maintain product confidentiality. Meanwhile, samples used as comparison groups were recaldent paste and pure cow's milk. RESULTS Each sample was analyzed for protein content using a biuret test and protein molecular weight using the sodium dodecyl sulfate-polyacrylamide gel electrophoresis test. The protein content in toothpaste is compared with the similarity of the molecular protein weight in toothpaste that contains recaldent. Protein was found in samples 2, 3, 5, 6, 7, and 8 through a biuret test, with a concentration of 1.82; 1.53; 2.76; 1.92; 1.85; and 3.2 μg/mL. However, the protein bands were only found in sample 5 with a molecular weight of 20.7 kDa, sample 6 with a molecular weight of 19.1 kDa, sample 7 with a molecular weight of 17.7 kDa, and sample 8 with 2 bands, namely, 28.7 and 39.7 kDa. CONCLUSIONS We found the presence of protein in children's toothpaste. The protein molecular weight of recaldent paste is 17.7 kDa. Toothpaste containing protein with its molecular weight similar to recaldent's are found in samples 5 and 6.
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Affiliation(s)
- Hendrik Setia Budi
- Department of Oral Biology, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
- Research Center, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
| | - Indah Pebriani
- Research Center, Faculty of Dental Medicine, Universitas Airlangga, Surabaya, Indonesia
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Remington BC, Westerhout J, Meima MY, Blom WM, Kruizinga AG, Wheeler MW, Taylor SL, Houben GF, Baumert JL. Updated population minimal eliciting dose distributions for use in risk assessment of 14 priority food allergens. Food Chem Toxicol 2020; 139:111259. [PMID: 32179163 DOI: 10.1016/j.fct.2020.111259] [Citation(s) in RCA: 102] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 01/08/2023]
Abstract
Food allergy and allergen management are important global public health issues. In 2011, the first iteration of our allergen threshold database (ATDB) was established based on individual NOAELs and LOAELs from oral food challenge in roughly 1750 allergic individuals. Population minimal eliciting dose (EDp) distributions based on this dataset were published for 11 allergenic foods in 2014. Systematic data collection has continued (2011-2018) and the dataset now contains over 3400 data points. The current study provides new and updated EDp values for 14 allergenic foods and incorporates a newly developed Stacked Model Averaging statistical method for interval-censored data. ED01 and ED05 values, the doses at which 1%, and respectively 5%, of the respective allergic population would be predicted to experience any objective allergic reaction were determined. The 14 allergenic foods were cashew, celery, egg, fish, hazelnut, lupine, milk, mustard, peanut, sesame, shrimp (for crustacean shellfish), soy, walnut, and wheat. Updated ED01 estimates ranged between 0.03 mg for walnut protein and 26.2 mg for shrimp protein. ED05 estimates ranged between 0.4 mg for mustard protein and 280 mg for shrimp protein. The ED01 and ED05 values presented here are valuable in the risk assessment and subsequent risk management of allergenic foods.
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Affiliation(s)
- Benjamin C Remington
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Joost Westerhout
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Marie Y Meima
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - W Marty Blom
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands.
| | - Astrid G Kruizinga
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Matthew W Wheeler
- Risk Evaluation Branch, National Institute for Occupational Safety and Health, Cincinnati, OH, United States
| | - Steve L Taylor
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
| | - Geert F Houben
- The Netherlands Organisation for Applied Scientific Research TNO, Zeist, the Netherlands
| | - Joseph L Baumert
- Food Allergy Research and Resource Program, University of Nebraska, Lincoln, USA
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21
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Doña I, Pérez‐Sánchez N, Eguiluz‐Gracia I, Muñoz-Cano R, Bartra J, Torres MJ, Cornejo‐García JA. Progress in understanding hypersensitivity reactions to nonsteroidal anti-inflammatory drugs. Allergy 2020; 75:561-575. [PMID: 31469167 DOI: 10.1111/all.14032] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/26/2019] [Accepted: 08/27/2019] [Indexed: 12/11/2022]
Abstract
Nonsteroidal anti-inflammatory drugs (NSAIDs), the medications most commonly used for treating pain and inflammation, are the main triggers of drug hypersensitivity reactions. The latest classification of NSAIDs hypersensitivity by the European Academy of Allergy and Clinical Immunology (EAACI) differentiates between cross-hypersensitivity reactions (CRs), associated with COX-1 inhibition, and selective reactions, associated with immunological mechanisms. Three phenotypes fill into the first group: NSAIDs-exacerbated respiratory disease, NSAIDs-exacerbated cutaneous disease and NSAIDs-induced urticaria/angioedema. Two phenotypes fill into the second one: single-NSAID-induced urticaria/angioedema/anaphylaxis and single-NSAID-induced delayed reactions. Diagnosis of NSAIDs hypersensitivity is hampered by different factors, including the lack of validated in vitro biomarkers and the uselessness of skin tests. The advances achieved over recent years recommend a re-evaluation of the EAACI classification, as it does not consider other phenotypes such as blended reactions (coexistence of cutaneous and respiratory symptoms) or food-dependent NSAID-induced anaphylaxis. In addition, it does not regard the natural evolution of phenotypes and their potential interconversion, the development of tolerance over time or the role of atopy. Here, we address these topics. A state of the art on the underlying mechanisms and on the approaches for biomarkers discovery is also provided, including genetic studies and available information on transcriptomics and metabolomics.
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Affiliation(s)
- Inmaculada Doña
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
| | - Natalia Pérez‐Sánchez
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
- Departamento de Medicina Universidad de Málaga Malaga Spain
| | - Ibon Eguiluz‐Gracia
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
| | - Rosa Muñoz-Cano
- Allergy Section Pneumology Department Hospital Clinic ARADyAL Universitat de Barcelona Barcelona Spain
- Clinical and Experimental Respiratory Immunoallergy (IRCE) August Pi i Sunyer Biomedical Research Institute (IDIBAPS) ARADyAL Barcelona Spain
| | - Joan Bartra
- Allergy Section Pneumology Department Hospital Clinic ARADyAL Universitat de Barcelona Barcelona Spain
- Clinical and Experimental Respiratory Immunoallergy (IRCE) August Pi i Sunyer Biomedical Research Institute (IDIBAPS) ARADyAL Barcelona Spain
| | - María José Torres
- Allergy Research Group Instituto de Investigación Biomédica de Málaga‐IBIMA ARADyAL Malaga Spain
- Allergy Unit Hospital Regional Universitario de Málaga Malaga Spain
- Departamento de Medicina Universidad de Málaga Malaga Spain
- Nanostructures for Diagnosing and Treatment of Allergic Diseases Laboratory Andalusian Center for Nanomedicine and Biotechnology‐BIONAND Malaga Spain
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23
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Eigenmann PA, Akdis C, Bousquet J, Grattan CE, Hoffmann-Sommergruber K, Jutel M. Food and drug allergy, and anaphylaxis in EAACI journals (2018). Pediatr Allergy Immunol 2019; 30:785-794. [PMID: 31539176 DOI: 10.1111/pai.13125] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 09/17/2019] [Indexed: 12/14/2022]
Abstract
The European Academy of Allergy and Clinical Immunology (EAACI) supports three journals: "Allergy," "Pediatric Allergy and Immunology (PAI)," and "Clinical and Translational Allergy (CTA)." One of the major goals of EAACI is to support health promotion in which prevention of allergy and asthma plays a critical role and to disseminate the knowledge of allergy to all stakeholders including the EAACI junior members. This paper summarizes the achievements of 2018 in anaphylaxis, and food and drug allergy. Main topics that have been focused are anaphylaxis, mechanisms of food allergy (FA), epidemiology of FA, food allergens, diagnosis of FA, prevention and control of FA, FA immunotherapy, drug allergy, and political agenda.
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Affiliation(s)
| | - Cezmi Akdis
- Swiss Institute of Allergy and Asthma Research (SIAF), University Zurich, Davos, Switzerland
| | - Jean Bousquet
- MACVIA-France, Fondation partenariale FMC VIA-LR, Montpellier, France.,INSERM U 1168, VIMA: Ageing and Chronic Diseases - Epidemiological and Public Health Approaches, Villejuif, France.,UMR-S 1168, Université Versailles St-Quentin-en-Yvelines, Montigny le Bretonneux, France.,Euforea, Brussels, Belgium
| | | | | | - Marek Jutel
- Department of Clinical Immunology, Wroclaw Medical University, Wrocław, Poland.,ALL-MED Medical Research Institute, Wrocław, Poland
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24
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Westerhout J, Baumert JL, Blom WM, Allen KJ, Ballmer-Weber B, Crevel RW, Dubois AE, Fernández-Rivas M, Greenhawt MJ, Hourihane JO, Koplin JJ, Kruizinga AG, Le TM, Sampson HA, Shreffler WG, Turner PJ, Taylor SL, Houben GF, Remington BC. Deriving individual threshold doses from clinical food challenge data for population risk assessment of food allergens. J Allergy Clin Immunol 2019; 144:1290-1309. [DOI: 10.1016/j.jaci.2019.07.046] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 06/24/2019] [Accepted: 07/22/2019] [Indexed: 10/26/2022]
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25
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Reier-Nilsen T, Michelsen MM, Lødrup Carlsen KC, Carlsen KH, Mowinckel P, Nygaard UC, Namork E, Borres MP, Håland G. Feasibility of desensitizing children highly allergic to peanut by high-dose oral immunotherapy. Allergy 2019; 74:337-348. [PMID: 30225844 DOI: 10.1111/all.13604] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 07/30/2018] [Accepted: 08/12/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND There are limited data on the feasibility, efficacy and safety of high-dose oral immunotherapy (OIT) in children highly allergic to peanuts. OBJECTIVE In children highly allergic to peanut, we primarily aimed to determine the feasibility of reaching the maximum maintenance dose (MMD) of 5000 mg peanut protein or, alternatively, a lower individual maintenance dose (IMD), by OIT up-dosing. Secondarily, we aimed to identify adverse events (AEs) and determine factors associated with reaching a maintenance dose. METHODS The TAKE-AWAY peanut OIT trial enrolled 77 children 5-15 years old, with a positive oral peanut challenge. Fifty-seven were randomized to OIT with biweekly dose step-up until reaching MMD or IMD and 20 to observation only. Demographic and biological characteristics, AEs, medication and protocol deviations were explored for associations with reaching maintenance dose. RESULTS All children had anaphylaxis defined by objective symptoms in minimum two organ systems during baseline challenge. The MMD was reached by 21.1%, while 54.4% reached an IMD of median (minimum, maximum) 2700 (250, 4000) mg peanut protein, whereas 24.5% discontinued OIT. During up-dosing, 19.4% experienced anaphylaxis. Not reaching the MMD was caused by distaste for peanuts (66.7%), unacceptable AEs (26.7%) and social reasons (6.7%). Increased peanut s-IgG4 /s-IgE ratio (OR [95% CI]: 1.02 [1.00, 1.04]) was associated with reaching MMD. CONCLUSION Although 75.5% of children with peanut anaphylaxis reached a maintenance dose of 0.25-5 g, only 21.1% reached the MMD. Distaste for peanuts and AEs, including high risk of anaphylaxis, limited the feasibility of reaching MMD.
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Affiliation(s)
- Tonje Reier-Nilsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Merethe Melbye Michelsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Karin C. Lødrup Carlsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Kai-Håkon Carlsen
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
| | - Petter Mowinckel
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
| | - Unni C. Nygaard
- Norwegian Institute of Public Health; Division for Infection Control and Environmental Health; Oslo Norway
| | - Ellen Namork
- Norwegian Institute of Public Health; Division for Infection Control and Environmental Health; Oslo Norway
| | - Magnus P. Borres
- Thermo Fisher Scientific; Uppsala Sweden
- Institute of Maternal & Child Health; Uppsala University; Uppsala Sweden
| | - Geir Håland
- Division of Paediatric and Adolescent Medicine; Oslo University Hospital; Oslo Norway
- Institute of Clinical Medicine; University of Oslo; Oslo Norway
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26
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Anagnostou K, Turner PJ. Myths, facts and controversies in the diagnosis and management of anaphylaxis. Arch Dis Child 2019; 104:83-90. [PMID: 29909382 PMCID: PMC6317446 DOI: 10.1136/archdischild-2018-314867] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 05/29/2018] [Accepted: 05/30/2018] [Indexed: 12/22/2022]
Abstract
Anaphylaxis is a serious systemic allergic reaction that is rapid in onset and may cause death. Despite numerous national and international guidelines and consensus statements, common misconceptions still persist in terms of diagnosis and appropriate management, both among healthcare professionals and patient/carers. We address some of these misconceptions and highlight the optimal approach for patients who experience potentially life-threatening allergic reactions.
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Affiliation(s)
- Katherine Anagnostou
- Department of Pediatrics, Section of Immunology, Allergy and Rheumatology, Texas Children’s Hospital, Houston, Texas, USA
- Pediatrics, Section of Immunology, Allergy and Rheumatology, Baylor college of Medicine, Houston, TX, USA
| | - Paul J Turner
- Section of Paediatrics, Imperial College London, London, UK
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27
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Roth C, Gangl C, Dalos D, Delle-Karth G, Neunteufl T, Berger R. Incidence of late-acquired stent malapposition of drug eluting stents with second generation permanent and biodegradable polymer coatings-A prospective, randomized comparison using optical coherence tomography. J Interv Cardiol 2018; 31:780-791. [PMID: 30479028 DOI: 10.1111/joic.12572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Revised: 10/13/2018] [Accepted: 10/22/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES AND BACKGROUND Polymer coatings of drug-eluting stents (DES) may induce allergic reactions and inflammation, resulting in late-acquired stent malapposition (LASM) with the risk of stent thrombosis. This study evaluated, if biodegradable polymer (BP) reduces the incidence of LASM compared to permanent polymer (PP) after treatment with newer generation DES. METHODS AND RESULTS Fifty patients with 59 lesions were randomized (2:1) to elective treatment with second generation PP-DES (n = 32, 39 stents), either Everolimus-eluting or Zotarolimus-eluting stents, or with BP-DES (Biolimus-eluting stents [BES]; n = 18, 20 stents) and underwent optical coherence tomography directly after implantation and after 1 year. After implantation acute stent malappositions (ASM) were documented in 30 stents (51%) distributed to 22 stents treated with PP-DES (56%) and 8 with BP-DES (40%; n.s.). After 1 year, late stent malappositions (LSM) were detected in 14 stents (24 %); ASM persisted (APSM) in 9 stents after one year (7 PP-DES-18%, 2 BES-10%), whereas ASM resolved in 21 stents. In addition, LASM was documented in nine stents including five stents without and four stents with additional APSM. All LASM were located in PP-DES (n = 9; 23%), none in BP-DES (P = 0.022). Compared to the reference lumen area, in-stent lumen area of stents without LASM was smaller due to neointimal hyperplasia (P = 0.021), whereas in-stent lumen area at maximum LASM of stents with LASM was larger due to positive remodeling (P = 0.002). CONCLUSIONS In conclusion the use of BP-DES reduced the occurrence of LASM due to positive remodeling compared to second generation PP-DES.
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Affiliation(s)
- Christian Roth
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | - Clemens Gangl
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | - Daniel Dalos
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria
| | - Georg Delle-Karth
- Department of Internal Medicine IV, Cardiology, Hospital of Hietzing, Vienna, Austria
| | - Thomas Neunteufl
- Department of Internal Medicine I, Cardiology, University Hospital of Krems, Krems an der Donau, Austria.,Karl Landsteiner Private University for Health Sciences, Krems an der Donau, Austria
| | - Rudolf Berger
- Department of Internal Medicine II, Cardiology, Medical University of Vienna, Vienna, Austria.,Department of Internal Medicine I, Cardiology and Nephrology, Hospital of St. John of God, Eisenstadt, Austria
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28
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Dubois AEJ, Turner PJ, Hourihane J, Ballmer-Weber B, Beyer K, Chan CH, Gowland MH, O'Hagan S, Regent L, Remington B, Schnadt S, Stroheker T, Crevel RWR. How does dose impact on the severity of food-induced allergic reactions, and can this improve risk assessment for allergenic foods?: Report from an ILSI Europe Food Allergy Task Force Expert Group and Workshop. Allergy 2018; 73:1383-1392. [PMID: 29331070 PMCID: PMC6032860 DOI: 10.1111/all.13405] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/12/2017] [Indexed: 11/29/2022]
Abstract
Quantitative risk assessment (QRA) for food allergens has made considerable progress in recent years, yet acceptability of its outcomes remains stymied because of the limited extent to which it has been possible to incorporate severity as a variable. Reaction severity, particularly following accidental exposure, depends on multiple factors, related to the allergen, the host and any treatments, which might be administered. Some of these factors are plausibly still unknown. Quantitative risk assessment shows that limiting exposure through control of dose reduces the rates of reactions in allergic populations, but its impact on the relative frequency of severe reactions at different doses is unclear. Food challenge studies suggest that the relationship between dose of allergenic food and reaction severity is complex even under relatively controlled conditions. Because of these complexities, epidemiological studies provide very limited insight into this aspect of the dose-response relationship. Emerging data from single-dose challenges suggest that graded food challenges may overestimate the rate of severe reactions. It may be necessary to generate new data (such as those from single-dose challenges) to reliably identify the effect of dose on severity for use in QRA. Success will reduce uncertainty in the susceptible population and improve consumer choice.
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Affiliation(s)
- A. E. J. Dubois
- University Medical Centre Groningen; Groningen The Netherlands
| | | | | | | | - K. Beyer
- Charité Universitätsmedizin Berlin; Berlin Germany
| | | | | | | | - L. Regent
- Anaphylaxis Campaign; Farnborough UK
| | - B. Remington
- The Netherlands Organisation for Applied Scientific Research (TNO); Zeist The Netherlands
| | - S. Schnadt
- German Allergy and Asthma Association (DAAB); Mönchengladbach DE
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29
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Abstract
PURPOSE OF REVIEW This review aims to provide an update of recent advances in the epidemiology, clinical features and diagnosis, and management of food-induced anaphylaxis (FIA). RECENT FINDINGS Food allergy prevalence and FIA rates continue to rise, but FIA fatalities are stable. Basophil and mast cell activation tests promise more accurate identification of food triggers. Oral, sublingual, and epicutaneous immunotherapy can desensitize a significant portion of subjects. Epinephrine use for FIA remains sub-optimal. As the burden of food allergy continues to increase, it appears that the corresponding increase in research focused on this epidemic is beginning to bear fruit. The stable number of FIA fatalities in the face of an ongoing epidemic indicates lives have already been saved. The emergence of new diagnostic tests and interventional therapies may transform the management of FIA in the coming years.
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Affiliation(s)
- Christopher P Parrish
- Department of Pediatrics and Internal Medicine, Division of Allergy and Immunology, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390-9063, USA.
| | - Heidi Kim
- Department of Pediatrics, University of Texas Southwestern Medical School, Dallas, TX, USA
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30
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Ballmer-Weber BK, Beyer K. Reply. J Allergy Clin Immunol 2018; 141:2323. [DOI: 10.1016/j.jaci.2018.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 02/23/2018] [Indexed: 10/14/2022]
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Satitsuksanoa P, Jansen K, Głobińska A, van de Veen W, Akdis M. Regulatory Immune Mechanisms in Tolerance to Food Allergy. Front Immunol 2018; 9:2939. [PMID: 30619299 PMCID: PMC6299021 DOI: 10.3389/fimmu.2018.02939] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Accepted: 11/29/2018] [Indexed: 12/13/2022] Open
Abstract
Oral tolerance can develop after frequent exposure to food allergens. Upon ingestion, food is digested into small protein fragments in the gastrointestinal tract. Small food particles are later absorbed into the human body. Interestingly, some of these ingested food proteins can cause allergic immune responses, which can lead to food allergy. So far it has not been completely elucidated how these proteins become immunogenic and cause food allergies. In contrast, oral tolerance helps to prevent the pathologic reactions against different types of food antigens from animal or plant origin. Tolerance to food is mainly acquired by dendritic cells, epithelial cells in the gut, and the gut microbiome. A subset of CD103+ DCs is capable of inducing T regulatory cells (Treg cells) that express anti-inflammatory cytokines. Anergic T cells also contribute to oral tolerance, by reducing the number of effector cells. Similar to Treg cells, B regulatory cells (Breg cells) suppress effector T cells and contribute to the immune tolerance to food allergens. Furthermore, the human microbiome is an essential mediator in the induction of oral tolerance or food allergy. In this review, we outline the current understanding of regulatory immune mechanisms in oral tolerance. The biological changes reflecting early consequences of immune stimulation with food allergens should provide useful information for the development of novel therapeutic treatments.
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