What is currently happening in the field of allergology? At the two-day Allergo Update 2016 in Cologne, allergists, dermatologists, ENT specialists, pediatricians and pneumologists from Germany, Austria and Switzerland were informed by renowned experts about the latest developments in this field. In the following, three presentations are singled out from the wealth of interesting topics.
Prof. Dr. med. Ludger Klimek, Center for Rhinology/Allergology, Wiesbaden, Germany, reported on innovative treatment approaches for allergic rhinitis. For symptomatic drug therapy, mainly intranasal and systemic antihistamines as well as intranasal corticosteroids are available.
The combination of intranasal azelastine and fluticasone in the special formulation of Dymista® nasal spray is particularly effective and clearly outperforms topical steroid preparations in terms of efficacy [1]. In specific immunotherapy (SIT), it has been common practice to either inject the allergen preparations subcutaneously (SCIT) or to apply them under the tongue in drop or tablet form (SLIT). Although sublingual application is currently the standard of mucosal immunotherapy, it is by no means proven that the sublingual mucosa is actually the most suitable of all oral mucosal regions for immunotherapy. Because the ratio of the number of dendritic cells and mast cells is considerably more favorable in the oral vestibule (in front of the lower dentition) than in the sublingual region behind the dentition, the vestibular mucosa theoretically offers a better alternative for mucosal immunotherapy [2]. Indeed, in a randomized pilot study conducted at four German centers, slight clinical advantages of vestibular immunotherapy (VIT) over conventional SLIT resulted. Statistically, no superiority was detectable, but numerically, adverse local reactions occurred less frequently with VIT. Also, VIT resulted in a trend toward earlier and greater increases in immunological markers (specific IgE-blocking factor, specific IgG4) [2].
The long therapy duration of conventional SIT places high demands on patient compliance and adherence. Therefore, well effective, low-risk, alternative immunotherapy forms with shorter treatment duration are sought. Influencing immune regulation by SPIREs (“synthetic peptide immuno-regulatory epitopes”) represents an attractive new treatment modality [3,4]. The treatment of cat allergic patients suffering from rhinoconjunctivitis for only three months proved to be very effective using allergen-specific synthetic immunoregulatory peptides from “Fel d 1”. Over at least two years, a long-lasting therapeutic effect with persistent tolerance could be achieved without further injections. Studies have also been successfully conducted in grass pollen, dust mite, and ragweed allergy sufferers.
Food allergies in children
Children are still more frequently affected by food allergies than adults. For example, 0.5% of all children in Europe develop a cow’s milk allergy in the first two years of life, which is usually only temporary, reported Prof. Kirsten Beyer, MD, Clinic for Pediatrics, Charité-Universitätsmedizin, Berlin. In Germany, every 50th child develops a clinically relevant chicken egg allergy proven by double-blind, placebo-controlled provocation in the first two years of life – in Greece, however, only every thousandth child. Half of the children affected lose the disease within a year. It is unclear why the children suddenly become clinically tolerant and can eat chicken egg again without any symptoms, although the specific IgE antibodies are still present, the speaker said. In Germany, 0.5% of all children already have a clinically manifest peanut allergy in the first two years of life. In striking contrast to cow’s milk or hen’s egg allergy, most sufferers retain their peanut allergy into adolescence and adulthood.
The three early childhood food allergens peanut, milk, and hen’s egg are responsible for most severe anaphylactic reactions in childhood [5]. Fortunately, professional anaphylaxis treatment according to guidelines has improved in recent years, Prof. Beyer reported. Data from the European Anaphylaxis Registry show that in 2011, only 12% of children and adolescents correctly received intramuscular epinephrine for severe anaphylactic reactions with respiratory or circulatory symptoms [6]. By 2014, this rate had doubled to 25%. However, there is still a shortfall of 75% until all patients are treated in emergencies according to guidelines, the speaker pointed out. She drew attention to the fact that recently the approval limit of the epinephrine auto-injector EpiPen® Junior was lowered. In young children under 15 kg body weight, only off-label use of the autoinjector has been possible so far. Now the mentioned autoinjector (0.15 mg adrenaline for intramuscular injection) is already approved for use from 7.5 kg body weight. It is also new that the adult autoinjector (EpiPen® with 0.3 mg epinephrine) should be used for children and adolescents weighing 25 kg or more.
Grass pollen can aggravate atopic eczema in sensitized individuals
Prof. Dr. med. Thomas Werfel, Clinic for Dermatology, Hannover Medical School, reported results of a study on atopic dermatitis and grass pollen sensitization [7]. In winter, subjects in the pollen provocation chamber were exposed to either grass pollen or pollen-free room air. On air-exposed skin not covered by clothing, flare-up reactions occurred due to pollen exposure. Later, reactions also appeared in textile-covered areas, probably after penetration of the grass pollen allergens through the uncovered skin by the hematogenous route. Prof. Werfel also pointed out that coexisting atopic eczema does not prevent SIT in patients with allergic rhinoconjunctivitis and/or mild allergic asthma.
Source: Allergo Update, February 26-27, 2016, Cologne, Germany
Literature:
- Klimek L, et al: Recent pharmacological developments in the treatment of perennial and persistent allergic rhinitis. Expert Opin Pharmacother 2016 [Epub ahead of print].
- Allam JP, et al: Immunologic response and safety in birch pollen sublingual versus oral vestibule immunotherapy. A pilot study. J Allergy Clin Immunol 2014; 133: 1757-1759.
- Worm M, et al: SPIREs: a new horizon for allergic disease treatment? Expert Rev Clin Immunol 2015; 11: 1173-1175.
- Prickett SR, et al: Immunoregulatory T cell epitope peptides. The new frontier in allergy therapy. Clin Exp Allergy 2015; 45: 1015-1026.
- Worm M, et al: Guideline on the management of IgE-mediated food allergy. Allergo J Int 2015; 24: 256-293.
- Grabenhenrich LB, et al: Anaphylaxis in children and adolescents. The European Anaphylaxis Registry. J Allergy Clin Immunol 2016. DOI: 10.1016/j.jaci.2015.11.015. [Epub ahead of print].
- Werfel T, et al: Exacerbation of atopic dermatitis on grass pollen exposure in an environmental challenge chamber. J Allergy Immunol 2015; 136: 96-103.
HAUSARZT PRAXIS 2016; 11(4): 34-36
DERMATOLOGIE PRAXIS 2016; 26(2): 48-49
