Eight tips for the implementation of the first licenced peanut allergy oral immunotherapy into clinical practice.

BACKGROUND: Shared learnings from the early use of novel therapies can aid in their optimization. The recent introduction of peanut oral immunotherapy (peanut OIT; Palforzia [Peanut (Arachis hypogaea) Allergen Powder-dnfp]) for peanut allergy addresses a significant unmet need but also highlights the requirement for consideration of several factors by both prescribers and patients. OBJECTIVE: To provide guidance for prescribers of licenced peanut OIT to facilitate treatment delivery and improve outcomes. METHODS: Clinicians with experience of licenced peanut OIT (United States n = 6, United Kingdom n = 1) participated in a series of interviews and group discussions designed to elicit tips for successful implementation. RESULTS: Clinicians identified 8 tips that were considered the most relevant, practical, and impactful for prescribers of Peanut (Arachis hypogaea) Allergen Powder-dnfp: (1) preparing to provide treatment, (2) assessing the medical indication for treatment and (3) shared decision making, (4) staff education, (5) establishing office processes, (6) managing patient expectations and using anticipatory guidance, (7) optimising adherence and (8) maintaining flexibility throughout the treatment process. In addition, a range of supporting materials (e.g., checklists and action plans) are provided. CONCLUSION: The introduction of a novel therapy often requires healthcare providers to modify or adopt practices to effectively employ the treatment. The provision of guidance based upon early real-world experiences of licenced peanut OIT may help inform clinical practice and improve treatment outcomes.

Is asthma associated with cognitive impairments? A meta-analytic review.

INTRODUCTION: Asthma is a chronic disease with significant health burden and socioeconomic and racial/ethnic disparities related to diagnosis and treatment. Asthma primarily affects the lungs, but can impact brain function through direct and indirect mechanisms. Some studies have suggested that asthma negatively impacts cognition, while others have failed to identify asthma-related cognitive compromise. We aimed to conduct a meta-analysis of cognition in individuals with asthma compared to that in healthy controls. We also examined the impact of some key potential moderators. METHOD: Data on cognitive outcome measures and sociodemographic, illness-related, and study-related variables were extracted from studies reporting cognitive test performance in individuals with asthma compared to that in controls. RESULTS: There was no evidence of publication bias. A random-effects model examining differences in task performance between 2017 individuals with asthma and 2131 healthy controls showed significant effects in the small to medium range. Cognitive deficits associated with asthma were global, with strongest effects on broader measures involving academic achievement and executive functioning, but with additional impact on processing speed, global intellect, attention, visuospatial functioning, language, learning, and memory. Severity of asthma was a key moderator, with greatest cognitive deficits associated with severe asthma. Cognitive burden was also greatest in asthma patients who were younger, males, from low socioeconomic backgrounds, and from racial/ethnic minorities. Effects were independent of type of population (child versus adult), type of study (norm-referenced versus control-referenced), or reported use of oral or inhaled corticosteroid medications. CONCLUSIONS: There is cognitive burden associated with asthma, particularly among vulnerable groups with severe asthma. This could be due to increased risk of intermittent cerebral hypoxia in severe asthma. The clinical need to assess cognition in individuals with asthma is underscored.

14 years of eosinophilic esophagitis: clinical features and prognosis.

OBJECTIVE: To determine the natural history of treated and untreated eosinophilic esophagitis (EE) and examine the presenting symptoms of EE. PATIENTS AND METHODS: Retrospective and prospective chart review of all patients diagnosed with EE at The Children's Hospital of Philadelphia. EE was defined as greater than 20 eosinophils per high power field after treatment with reflux medications. RESULTS: We identified 620 patients in our database in the last 14 years and 330 patients with greater than 1 year of follow-up for analysis. The number of new EE patients has increased on an annual basis. Of the patients presenting with EE, 68% were younger than 6 years old. Reflux symptoms and feeding issues/failure to thrive were the most common presenting symptoms for EE. Eleven patients had resolution of all of their food allergies and 33 patients had resolutions of some of their food allergies. No patients have progression of EE into other gastrointestinal disorders. CONCLUSIONS: EE is a chronic disease with less than 10% of the population developing tolerance to their food allergies. EE does not progress into other gastrointestinal diseases.

Food Intolerance and childhood asthma: what is the link?

Food allergies and asthma are increasing worldwide. It is estimated that approximately 8% of children aged <3 years have food allergies. Foods can induce a variety of IgE-mediated, cutaneous, gastrointestinal, and respiratory reactions. The most common foods responsible for allergic reactions in children are egg, milk, peanut, soy, fish, shellfish, and tree nuts. Asthma alone as a manifestation of a food allergy is rare and atypical. Less than 5% of patients experience wheezing without cutaneous or gastrointestinal symptoms during a food challenge. In addition to acute respiratory symptoms, a food allergy may also induce airway hyper-responsiveness beyond the initial reaction. This process can occur in patients who do not demonstrate a decrease in lung function during the reaction. Inhalation of aerosolized food particles can cause respiratory symptoms in selected food-allergic individuals, particularly with fish and shellfish during cooking and aerosolization. However, this has not been demonstrated with the smelling of, or casual contact with, peanut butter. Rarely, food additives such as sulfating agents can cause respiratory reactions. This reaction occurs primarily in patients with underlying asthma, particularly in patients with more severe asthma. In contrast, there is no convincing evidence that tartrazine or monosodium glutamate can induce asthma responses. Although food-induced asthma is rare, it is common for patients and clinicians to perceive that food can trigger asthma. Avoidance of specific foods or additives has not been shown to improve asthma, even in patients who may perceive that a particular food worsens their asthma.However, patients with underlying asthma are more likely to experience a fatal or near-fatal food reaction. Food reactions tend to be more severe or life threatening when they involve the respiratory tract. The presence of a food allergy is a risk factor for the future development of asthma, particularly for children with sensitization to egg protein. The diagnosis of a food allergy includes skin or in vitro testing as an initial study when the history suggests food allergy. While negative testing generally rules out a food allergy, positive testing should be followed by a food-challenge procedure for a definitive diagnosis. The CAP-RAST FEIA (CAP-radioallergosorbent test [RAST] fluoroenzyme immunoasssay system [FEIA]) is an improved in vitro measure that in some cases may decrease the need for food challenges. However, similar to skin testing and the RAST, there is good sensitivity but poor specificity, such that specific challenges are often warranted.

Late diagnosis of tree nut and sesame allergy in patients previously sensitized but tolerant to peanut.

BACKGROUND: Recent studies have indicated that tolerance to peanut can occur in patients with a history of peanut allergy. Tree nut and sesame allergies have been reported to occur at increased incidence in patients with peanut allergy. Although the coexistence may be simply due to a predisposition to food allergy in these individuals, cross-reactivity has been demonstrated between peanut and tree nuts and between peanut and sesame seed. OBJECTIVE: To describe 3 patients previously sensitized but tolerant to peanut who were subsequently diagnosed as having either tree nut or sesame allergy. METHODS: All the patients had a clinical history of peanut sensitivity and underwent follow-up peanut skin testing to commercial extracts using a bifurcated needle followed by a graded peanut challenge. One patient had a previous positive radioallergosorbent test reaction to sesame and underwent a graded sesame challenge. RESULTS: All the patients had negative peanut challenge results. Two patients subsequently had exposure to tree nuts at home and had systemic reactions and positive skin test reactions to the incriminated tree nut. One patient had a positive challenge reaction to sesame. CONCLUSION: Demonstration of tolerance to peanut may falsely reassure patients and physicians that patients no longer need to avoid tree nuts or sesame. Tree nut and sesame allergies can exist or develop in patients despite the development of tolerance to peanut.

Treatment of eosinophilic esophagitis with specific food elimination diet directed by a combination of skin prick and patch tests.

BACKGROUND: Eosinophilic esophagitis (EE) is a recently described disorder identified in patients with symptoms suggestive of gastroesophageal reflux disease (GERD) but unresponsive to conventional reflux therapies. Therapies have included corticosteroids, elemental diet, and diet restriction. We report our experience with skin prick and atopy patch testing and food elimination diets in patients diagnosed as having EE. OBJECTIVE: To identify food antigens that cause EE and the characteristics of patients who respond to food elimination vs those who are unresponsive. METHODS: Patients diagnosed as having EE had restricted diets based on skin prick and atopy patch testing results. Additional biopsies were performed after 4 to 8 weeks of restricted diet. Demographics, atopic tendencies, and food antigens were identified retrospectively in our food allergy database. RESULTS: A total of 146 patients diagnosed as having EE were evaluated with skin prick and atopy patch testing. Thirty-nine patients had unequivocal demonstration of food causing EE, with normalization of biopsy results on elimination and reoccurrence on reintroduction. An additional 73 patients, for a total 112 (77%) of 146 patients, had resolution of their EE as demonstrated by biopsy results. Fifteen (10%) of 146 patients were nonresponders manifested by no significant reduction in esophageal eosinophils despite restricted diet based on skin prick and atopy patch testing. Egg, milk, and soy were identified most frequently with skin prick testing, whereas corn, soy, and wheat were identified most frequently with atopy patch testing. CONCLUSION: In more than 75% of patients with EE, both symptoms and esophageal inflammation can be significantly improved with dietary elimination of foods. Skin prick and atopy patch testing can help identify foods in most patients.

Correlation of initial food reactions to observed reactions on challenges.

BACKGROUND: Food allergies occur in 2% to 3% of the pediatric population. These reactions can vary from mild cutaneous manifestations to severe life-threatening reactions. Limited information is available on which specific factors may predict the severity of subsequent reactions. OBJECTIVE: To determine whether the organ system or the specific food involved in the initial allergic reaction predicts the outcome of subsequent food challenge. METHODS: Retrospective review of all food sensitive children who underwent food challenges at The Children's Hospital of Philadelphia, Philadelphia, PA, in a 5-year period (n = 998 challenges). The specific food, initial symptom on presentation, and reaction on open challenges were recorded. RESULTS: A total of 413 of 998 food challenges produced positive results. Milk, egg, and peanut were the most common foods to be associated with a positive challenge result. The most common presentation of food allergy was cutaneous followed by multiorgan reactions. Peanut, milk, and egg sensitivities were more likely to cause a multiple-organ system reaction on challenge than wheat or other foods. Patients with egg allergy were more likely to have a different reaction on rechallenge than other foods. CONCLUSIONS: Milk, egg, and peanut are the most common foods associated with food challenges. Patients will typically experience similar reaction on re-exposure to the initial reaction. However, multiple-organ system reactions can occur after any initial clinical presentation, with milk, egg, and peanut having more multiple-organ reactions than other foods.

The use of skin prick tests and patch tests to identify causative foods in eosinophilic esophagitis.

BACKGROUND: Eosinophilic esophagitis is a disease entity in which patients have (1) elevated eosinophils on esophageal biopsy and (2) symptoms of gastroesophageal reflux. The symptoms do not improve on aggressive acid blockade but do improve on elimination diet or corticosteroid treatment, which tentatively links food allergies to this disorder. OBJECTIVE: The purpose of this study was to identify potential food antigens in eosinophilic esophagitis. METHODS: Patients with eosinophilic esophagitis were identified by biopsy. Potential food antigens were identified prospectively by skin prick testing and patch testing, which were performed through use of standard methods. Atopic tendencies, demographics, and potential food allergies were identified. Repeat esophageal biopsies were reviewed when possible. RESULTS: A total of 26 patients (22 male, 4 female) with a biopsied-confirmed diagnosis of eosinophilic esophagitis underwent both skin prick testing and patch testing to identify potential causative foods. Milk and egg were the most common positive foods with skin prick testing. Wheat was the most common positive food with patch testing. The patients were advised to avoid positive foods as identified by skin prick testing and patch testing. In all, 18 patients had resolution of their symptoms, 6 patients had partial improvement, and 2 were lost to follow-up. Overall, after intervention, esophageal eosinophil counts improved from 55.8 to 8.4 eosinophils per high-power field. The foods most commonly identified by patients as causing symptoms were milk and egg. CONCLUSION: The combination of skin prick testing and patch testing can identify potential causative foods that might contribute to the pathogenesis of eosinophilic esophagitis.