Bibliographic updates

April 2017


Claude Molina et Jacques Gayraud

1.    Epicutaneous immunotherapy for the treatment of peanut allergy in children and young adults.
2.    Options in immunotherapy for peanut allergy.
3.    Physical health conditions and quality of life in adults with primary immunodeficiency diagnosed during childhood
4.    Associations between outdoor fungal spores and childhood and adolescent asthma hospitalizations
5.    Symptomatic treatment of pollen-related allergic rhinoconjunctivitis in children: randomized controlled trial.

I. Epicutaneous immunotherapy for the treatment of peanut allergy in children and young adults.
S.M.Jones et al JACI2017April  139 4 1242-1252                             
The authors sought to evaluate the clinical, safety and immunologic effects of this immunotherapy by using Viaskin patches, V 100µg or V 250µg in a multicenter controlled study of 74 participants (age 4-25years) during 52 weeks.
Treatment success (defined as passing a 5044 mg oral food challenge protein or 140 fold increase in successfully consumed from baseline) was achieved in respectively 11 patients (46%), V 100 and 12 patients V 250 (48%) compared with placebo: 3 (12%). It was higher among younger children (4-11 years). Administration was safe, except local mild patch-site reactions. There were significant changes in immune pathways like in other immunotherapies for food-allergy.                      
In conclusion, this peanut epicutaneous therapy was safe in spite of a modest response after 52 weeks.

II. Options in immunotherapy for peanut allergy
Y.Katz, M.R. GoldbergJACI April 2017 139 1135-1136     
These pediatricians review all the options for the treatment of peanut allergy, the prevalence of which is increasing and reduces quality of life for both patients and their families. Meticulous avoidance was for many years the only option but do not prevent fatal accidents due to inadvertent consumption (requiring to carry epinephrine auto-injector).
Since 2005, protocols of Oral Immunotherapy (OIT) were published but was long, time-consuming with sometimes severe adverse effects and not always sustained desensitization. Indeed in older patients, these adverse effects may be minimized and the treatment protocol accelerated through addition of Omalizumab but at high cost sublingual routes can be used alternately but do not allow a high tolerable dose.
So the novel modality of Immunotherapy by epicutaneous route seems to be an important addition to the growing armamentarium, despite its limitations. There are several encouraging messages from this recent study:
1) There are few adverse effects and they are mild  
2) In youngest children the threshold of reaction to peanut is significantly increased
3) There was a high rate of adherence to treatment.                 
It certainly could have a place in providing an initial treatment for severe peanut allergy, avoiding anaphylaxis from accidental exposure and enabling admission to subsequent immunotherapy programs.

III. Physical health conditions and quality of life in adults with primary immunodeficiency (PID) diagnosed during childhood:
A French reference center for PIDs (CEREDIH) study.
V. Barlogis et al JACI April 2017 139  4 1275-1281
Most children with PID now reach adulthood and to investigate long-term morbidity, and their quality of life, the French reference center initiated a prospective multicenter follow-up program.                   
Among the 889 participants, 329 were adults, 58 undergone stem-cell transplantation; the mean age of participation was 27 years. The major findings are as follows:         
-    All but 12% experienced a severe (grade 3) or life-threatening condition (grade 4),
-    7,6% of the patients reported a malignancy.    
-    Adults scored significantly lower for all domains of quality of life.
These findings highlight that these long surviving adults with PID diagnosed during childhood, experienced a heavy burden of health conditions which affect their quality of life and underline the need to closely monitor this vulnerable population.

IV. Associations between outdoor fungal spores and childhood and adolescent asthma hospitalizations                    
R. Tham et al JACI April 2017, 139 4 1140-1147                      
Some outdoor fungi can be associated with asthma exacerbations, little is known about potential interactions with other factors such Rhinovirus respiratory tract infections (HRV) or fungal sensitization. The Australian authors studied the Melbourne cohort of 644 children and adolescents (2-17 years) hospitalized for asthma and collected data   on outdoor fungi.                                       
4 allergic species were significantly associated with asthma hospitalizations: Alternaria, and less known species: Leptosphaeria, Coprinus, Drechsfera independent of HRV infection. Moreover delayed effects were found for fungal exposure up to 3 days before hospitalization.                                              
At last, associations with Alternaria, Coprinus, and Drechsfera were stronger in those sensitized to Cladosporium, probably due to cross-reactivity between fungal species.
In conclusion, outdoor fungi can contribute to asthma hospitalization. Is this a special feature of Australasian climate? This requires future researches and closer attention to all environmental factors.

V. Symptomatic treatment of pollen-related allergic rhinoconjunctivitis in children: randomized controlled trial.
J. B. Wartna et al, Allergy 201772 4
Although the main symptomatic treatments are intranasal corticosteroids (INCS) (daily or on demand) and oral antihistamines, it remains unclear which treatment provides the best relief of symptoms. Therefore, this study examines whether daily use of INCS is superior to on-demand use or to oral antihistamines on demand.
A single-blinded randomized controlled trial in children (aged 6–18 years) with pollen-allergy is performed. Patients received either INCS daily (fluticasone propionate), INCS on demand (fluticasone propionate) or oral antihistamine on demand (levocetirizine) for 3 months during the grass pollen season. A daily online symptom diary on both nose and eye symptoms was completed. The primary outcome was the percentage of symptom-free days.
A total of 150 children were randomized. The percentage symptom-free days was in favour of INCS on demand (30%) compared with INCS daily or with antihistamine on-demand group but not significant). Patients in the INCS on-demand group used on average 61% less fluticasone than patients in the INCS daily group during the study period
This trial with three parallel treatment groups shows that INCS daily was not superior to INCS on demand or to antihistamine on demand regarding the number of symptom-free days. An on-demand INCS strategy has the advantage of a lower overall corticosteroid exposure and less costs.

Your comments and questions are welcome at the following addresses:

Claude Molina                         
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Jacques Gayraud
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Last updated 28 June 2017