Historic Change Imminent in Food Allergy, Asthma Treatments

Ingrid Hein

February 13, 2019

Medicine is on the cusp of embracing an entirely new approach to the treatment of food allergy, according to American Academy of Allergy, Asthma and Immunology (AAAAI) President Robert Wood, MD.

For example, "we anticipate that a product will be approved for the treatment of peanut allergy in the next 2 years," said Wood.

"I've been doing this for 30 years," he added. "Until now, all we've had to offer is avoidance and treatment" after accidental exposure.

The new approach to food allergy is actually an old approach, and in line with the way all other allergies are managed, Wood told Medscape Medical News. But "slow exposure is a very different concept for food allergy."

The integration and personalization of these new approaches will be in the spotlight next week at the AAAAI 2019 Meeting in San Francisco.

There has been real concern about deliberate exposure because of the risks involved. In the past, exposing a "patient with severe peanut allergy has not been worth the risk," said Wood. But specialists are starting to look at this differently.

One debate at the meeting will be on the use of immunotherapy to treat food allergy in clinical practice. "This is especially controversial," Wood explained, "but we know that many practitioners are doing some form of immunotherapy, even buying products, such as peanut butter, from the grocery store."

New Biologics

There has also been substantial progress in the development of humanized monoclonal IgE antibodies against common allergens. Biologics that deliver these antibodies will become increasingly available, said David Chaplin, MD, PhD, scientific chair for the AAAAI annual meeting planning committee.

"For example, monoclonal antiragweed lgE is becoming available, and shows potential for new diagnostic approaches and possibly new therapeutic approaches," he told Medscape Medical News.

Research on naturally occurring antigens and antigen-specific IgE and lgG antibodies will be presented by Scott Smith, MD PhD, from Vanderbilt University Medical Center in Nashville, Tennessee.

Specialists are now looking closely at biologics. "There are a lot of biologic agents; we are now trying to determine which biologics will be useful in which subsets of patients," Chaplin explained.

For example, several presentations will concern the PROSPERO clinical trial, a prospective study designed to evaluate predictors of clinical effectiveness in response to omalizumab. There will also be presentations on trials of mepolizumab, reslizumab, dupilumab, and benralizumab.

Ways to identify new pathogenic mechanisms of disease, such as the use of artificial intelligence to sort through huge amounts of data, will be discussed. And a keynote on the use genomic, proteomic, and metabolomic data to map the course of disease, which could lead to better models of asthma and other immune and inflammation disorders, will be delivered by Eric Schadt, PhD, from the Icahn School of Medicine at Mount Sinai. Chaplin said he is looking forward to this talk in particular.

During a series of presentations on the effects of the urban environment on asthma, Leonard Bacharier, MD, from the Washington University School of Medicine in St. Louis, will explore how the presence of mites and cockroaches affects asthma in early childhood.

Microbiome Fueling Several Research Studies

The association between the microbiome and allergy will also be in the spotlight. "There are many theories about why people have more allergies, and a lot of them revolve around the microbiome," Wood reported.

One of the theories, the hygiene hypothesis, suggests that our environment is too clean. "Some researchers think that if the immune system is not being stimulated by normal infectious agents, it focuses instead on allergy," he said.

Among the research presented on this topic will be a talk on farm exposure and the infant gut microbiome by Julia Thorsen, MD, from the University of Wisconsin–Madison.

The systemic regulation of allergic inflammation and ways to alter the microbiome with probiotics and other methods will be discussed by Cathryn Nagler, MD, from the University of Chicago.

DNAzymes are also a hot topic. "The potential to modify gene expression is huge." Chaplin told Medscape Medical News.

Potential for Gene Modification

"While ethical issues preclude most studies from modifying abnormally functioning genes in the germ line, there is substantial interest in using genetic techniques to modify gene function in somatic cells," Chaplin explained.

For example, there is great potential if you can modify bone marrow cells with DNAzymes and then transplant them back to the donor. "Researchers are working to develop guidelines for this kind of potential therapy," he reported.

Most of the 7000 AAAAI members attend this meeting, said Wood. "We are looking forward to it, and expect a really good turnout in San Francisco this year."

Wood reports receiving research grants from Aimmune, Astellas, DBV Technologies, HAL-Allergy, Sanofi, and Regeneron. Chaplin has disclosed no relevant financial relationships.

Updated February 21, 2019 to correct Julia Thorsen's affiliation.

Follow Medscape on Twitter @Medscape and Ingrid Hein @ingridhein

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