Oral immunotherapy for food allergy

Current Opinion in Pediatrics

Volumn 22, Issue 6, 2010, Pages 765-770

  Vickery, Brian P ^a   Burks, Wesley ^a  

^a DUKE UNIVERSITY SCHOOL OF MEDICINE   (United States)

Author keywords

desensitization; food allergy; oral immunotherapy; tolerance

Indexed keywords

ADRENALIN; ALLERGEN; ANTIHISTAMINIC AGENT; ARACHIS OIL; BRONCHODILATING AGENT; EGG ALLERGEN; FISH OIL; FISH PROTEIN; FOOD ALLERGEN; IMMUNOGLOBULIN E; MILK ALLERGEN; PEANUT ANTIGEN; PLACEBO; UNCLASSIFIED DRUG;

ANAPHYLAXIS; ASTHMA; CLINICAL TRIAL; DESENSITIZATION; DRUG EFFICACY; DRUG SAFETY; EGG ALLERGY; FISH ALLERGY; FOOD ALLERGY; HUMAN; IMMUNOLOGICAL TOLERANCE; IMMUNOMODULATION; IMMUNOTHERAPY; MILK ALLERGY; NONHUMAN; ORAL IMMUNOTHERAPY; PEANUT ALLERGY; PRIORITY JOURNAL; REVIEW; T LYMPHOCYTE;

ADMINISTRATION, ORAL; ALLERGENS; DESENSITIZATION, IMMUNOLOGIC; FOOD HYPERSENSITIVITY; HUMANS;

EID: 78649503934     PISSN: 10408703     EISSN: None     Source Type: Journal    
DOI: 10.1097/MOP.0b013e32833f5fc0     Document Type: Review

References (33)

1. Chafen JJS, Newberry SJ, Riedl MA, et al. Diagnosing and managing common food allergies: A systematic review. JAMA 2010; 303:1848-1856. This meta-analysis highlighted the inherent difficulties of making the proper diagnosis of food allergy, including overinterpretation of serological testing.
2. Branum AM, Lukacs SL. Food allergy among children in the United States. Pediatrics 2009; 124:1549-1555. Using data from the National Health Interview Survey and National Hospital Discharge Survey, Centers for Disease Control investigators documented the increasing prevalence of food allergy among US children over the period 1997-2007.
3. Venter C, Arshad SH, Grundy J, et al. Time trends in the prevalence of peanut allergy: Three cohorts of children from the same geographical location in the UK. Allergy 2010; 65:103-108.
4. Gupta R, Sheikh A, Strachan DP, Anderson HR. Time trends in allergic disorders in the UK. Thorax 2007; 62:91-96.
5. Savage JH, Matsui EC, Skripak JM, Wood RA. The natural history of egg allergy. J Allergy Clin Immunol 2007; 120:1413-1417.
6. Skripak JM, Matsui EC, Mudd K, Wood RA. The natural history of IgEmediated cow's milk allergy. J Allergy Clin Immunol 2007; 120:1172-1177.
7. Sicherer SH, Sampson HA. Food allergy. J Allergy Clin Immunol 2010; 125 (Suppl. 2):S116-S125. A comprehensive clinical and scientific review of food allergy, updated for the 2010 Primer of the American Academy of Allergy, Asthma, & Immunology.
8. Avery NJ, King RM, Knight S, Hourihane JO. Assessment of quality of life in children with peanut allergy. Pediatr Allergy Immunol 2003; 14:378-382.
9. Scurlock A, Vickery B, Hourihane J, Burks A. Pediatric food allergy and mucosal tolerance. Mucosal Immunol 2010; 3:345-354. This review describes the immunological mechanisms of oral tolerance and how these principles may be therapeutically exploited in the treatment of allergic disease.
10. Freeman J. 'Rush' inoculation, with special reference to hay-fever treatment. Lancet 1930; 215:744-747.
11. Oppenheimer JJ, Nelson HS, Bock SA, et al. Treatment of peanut allergy with rush immunotherapy. J Allergy Clin Immunol 1992; 90:256-262.
12. Nelson HS, Lahr J, Rule R, et al. Treatment of anaphylactic sensitivity to peanuts by immunotherapy with injections of aqueous peanut extract. J Allergy Clin Immunol 1997; 99 (6 Part 1):744-751.
13. Patriarca G, Nucera E, Roncallo C, et al. Oral desensitizing treatment in food allergy: Clinical and immunological results. Aliment Pharmacol Ther 2003; 17:459-465.
14. Meglio P, Bartone E, Plantamura M, et al. A protocol for oral desensitization in children with IgE-mediated cow's milk allergy. Allergy 2004; 59:980-987.
15. Longo G, Barbi E, Berti I, et al. Specific oral tolerance induction in children with very severe cow's milk-induced reactions. J Allergy Clin Immunol 2008; 121:343-347.
16. Staden U, Rolinck-Werninghaus C, Brewe F, et al. Specific oral tolerance induction in food allergy in children: Efficacy and clinical patterns of reaction. Allergy 2007; 62:1261-1269.
17. Buchanan AD, Green TD, Jones SM, et al. Egg oral immunotherapy in nonanaphylactic children with egg allergy. J Allergy Clin Immunol 2007; 119:199-205.
18. Narisety SD, Skripak JM, Steele P, et al. Open-label maintenance after milk oral immunotherapy for IgE-mediated cow's milk allergy. J Allergy Clin Immunol 2009; 124:610-612. Although the double-blinded RCT of milk OIT showed a convincing clinical effect, most patients remained incompletely desensitized and without significant immunologic changes. This study shows that extended treatment with higher doses may be necessary to achieve these endpoints.
19. Nowak-Wegrzyn A, Bloom KA, Sicherer SH, et al. Tolerance to extensively heated milk in children with cow's milk allergy. J Allergy Clin Immunol 2008; 122:342-347; 347.e1-347.e2.
20. Lemon-Mulé H, Sampson HA, Sicherer SH, et al. Immunologic changes in children with egg allergy ingesting extensively heated egg. J Allergy Clin Immunol 2008; 122:977e1-983e1.
21. Shreffler WG, Wanich N, Moloney M, et al. Association of allergen-specific regulatory T cells with the onset of clinical tolerance to milk protein. J Allergy Clin Immunol 2009; 123:43.e7-52.e7. Although regulatory T cells are commonly implicated in the development of oral tolerance in mice, there is little high-quality evidence that this is true in humans. This study shows that tolerance of heated milk protein is associated with higher numbers of functionally active milk-specific T-regs.
22. Wanich N, Nowak-Wegrzyn A, Sampson HA, Shreffler WG. Allergen-specific basophil suppression associated with clinical tolerance in patients with milk allergy. J Allergy Clin Immunol 2009; 123:789.e20-794.e20. The same group showed that basophils, key effector cells in allergic inflammation, are also suppressed in heated milk-tolerant patients.
23. Jones SM, Pons L, Roberts JL, et al. Clinical efficacy and immune regulation with peanut oral immunotherapy. J Allergy Clin Immunol 2009; 124:292-300. This landmark study was the first to show that OIT could be used in peanut-allergic patients to modify the immune response and induce clinical desensitization.
24. Skripak JM, Nash SD, Rowley H, et al. A randomized, double-blind, placebocontrolled study of milk oral immunotherapy for cow's milk allergy. J Allergy Clin Immunol 2008; 122:1154-1160.
25. Clark AT, Islam S, King Y, et al. Successful oral tolerance induction in severe peanut allergy. Allergy 2009; 64:1218-1220. This small clinical study adapted the protocol of Jones et al. and used a baseline food challenge to formally prove a desensitization effect in a British cohort.
26. Blumchen K, Ulbricht H, Staden U, et al. Oral peanut immunotherapy in children with peanut anaphylaxis. J Allergy Clin Immunol 2010; 126:83.e1- 91.e1. Like Clark et al., this group used a food challenge at study entry to show desensitization with OIT in a European cohort. In addition, this group performed extensive immunologic analysis. These two studies lend significant scientific support to the OIT approach.
27. Hofmann AM, Scurlock AM, Jones SM, et al. Safety of a peanut oral immunotherapy protocol in children with peanut allergy. J Allergy Clin Immunol 2009; 124:286.e6-291.e6. Safety data from the trial by Jones et al., show that, in contrast to subcutaneous peanut immunotherapy, OIT is generally well tolerated. Allergic side-effects are common but generally mild, and anaphylaxis is rare.
28. Varshney P, Steele PH, Vickery BP, et al. Adverse reactions during peanut oral immunotherapy home dosing. J Allergy Clin Immunol 2009; 124:1351-1352. This study highlights the role of pro-allergic risk factors which interact with OIT and make dosing reactions more likely to occur. Accounting for these risk factors in dosing protocols has improved the side-effect profile.
29. National Institute of Allergy and Infectious Diseases; Consortium of Food Allergy Research. Oral immunotherapy for childhood egg allergy [Internet]. Clinicaltrials.gov. Bethesda: National Library of Medicine. http:// clinicaltrials. gov/ct2/show/NCT00461097. [Accessed July 2010]
30. Duke University, University of Arkansas. Mucosal immunotherapy for peanut allergy [Internet]. Clinicaltrials.gov. Bethesda: National Library of Medicine. http://clinicaltrials.gov/ct2/show/NCT00597675. [Accessed July 2010]
31. Fisher HR, Toit GD, Lack G. Specific oral tolerance induction in food allergic children: Is oral desensitisation more effective than allergen avoidance? A meta-analysis of published RCTs. Arch Dis Child 2010. [Epub ahead of print] OIT appears to be more effective than allergen avoidance in this small metaanalysis, although this did not reach statistical significance due to the small number of rigorous studies included. The inclusion of egg and peanut OIT studies in progress may change this result.
32. Sheikh A, Venderbosch I, Nurmatov U. Oral immunotherapy for peanut allergy. BMJ 2010; 340:c2938.
33. Thyagarajan A, Varshney P, Jones SM, et al. Peanut oral immunotherapy is not ready for clinical use. J Allergy Clin Immunol 2010; 126:31-32. This editorial, co-authored by US food allergy experts, identifies the unresolved questions pertaining to OIT and calls for additional study prior to its clinical implementation.