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Medical Journal Review

September 2015

WAO Reviews - Editors' Choice

The Editors select articles for their importance to clinicians who care for patients with asthma and allergic/immunologic diseases, and whenever possible they seek articles that everyone can access freely. The Editors’ Choice comes to you each month from Juan Carlos Ivancevich, MD, WAO Web Editor-in-Chief, and summary author, John J. Oppenheimer, MD, FACAAI, FAAAAI, WAO Reviews Editor.

1. Recombinant allergens in specific immunotherapy

Nandy A, Häfner D, Klysner S. Recombinant allergens in specific immunotherapy. Allergo Journal International 2015; 24(5): 142-151.

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This is a comprehensive review of the role of recombinant DNA technology’s ability to improve allergy immunotherapy. As noted by the authors, the use of this technology allows us to fine tune our conventional allergy extracts, utilizing only components that are relevant to a specific patient’s illness.   Furthermore, by using this technology, it will be easier to insure manufacturers reduce the lot-to-lot variability in extract potency. Lastly, the authors explore unmodified recombinant allergens, hypoallergenic variants, which maintain immunogenicity while decreasing IgE reactivity. Certainly, many of us have seen the utility of this technology in our diagnostic armamentarium; now we can look forward to its potential role in our therapeutic arm, too.

2. Report from the National Institute of Allergy and Infectious Diseases workshop on drug allergy

Wheatley LM, Plaut M, Schwaninger JM, Banerji A, Castells M et al. Report from the National Institute of Allergy and Infectious Diseases workshop on drug allergy. Journal of Allergy and Clinical Immunology 2015; 136(2): 262-271. (doi:http://dx.doi.org/10.1016/j.jaci.2015.05.027)                      

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This document is the workshop summary from the expert panel meeting on drug allergy of the National Institute of Allergy and Infectious Diseases of the National Institutes of Health. This panel was composed of experts in the field of drug allergy from around the world who were assembled to discuss the current state of drug allergy research. It provides an excellent review of our current understanding of drug allergy, stressing issues such as epidemiology, phenotypes, and clinical manifestations, as well as mechanism of reactions, diagnostic testing, and recommendations for future research in the field.  Many of their recommendations regarding future research will ring true to the practicing allergist, such as:

  • Developing and validating skin test reagents as well as in vitro tests for drugs which likely have an IgE mediated mechanism for which we presently have no reliable test
  • Improving the sensitivity and specificity of currently available tests
  • Developing optimal desensitization protocols through multicenter trials
  • Developing risk mitigation strategies for patients that require frequent desensitization
  • Evaluating the use of pretreatment agents such as omalizumab for improving the safety and efficacy of drug desensitization.

3. The clinical utility of basophil activation testing in diagnosis and monitoring of allergic disease

Hoffman HJ, Santos AF, Mayorga C, Nopp A, Eberlein B et al. The clinical utility of basophil activation testing in diagnosis and monitoring of allergic disease. European Journal of Allergy and Clinical Immunology 2015; published online ahead of print, 8 September. (doi:10.1111/all.12698)

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In this EAACI Task force position paper, the authors provide an overview of the practical and technical details as well as the clinical utility of the Basophil Activation Test (BAT) in the diagnosis and management of allergic diseases. The BAT is the result of several scientific breakthroughs including the development of flow cytometry, discovery of activation markers such as CD63 and unique markers identifying basophil granulocytes. It has the ability to measure basophil response to allergen crosslinking IgE on between 150 and 2000 basophil granulocytes using less than 0.1 ml fresh blood. In this position paper the authors state that BAT can be used in the diagnostic evaluation of patients with food allergy, insect venom allergy, and drug allergy as well as chronic urticaria. They go on to note that basophil sensitivity may be used to monitor patients on allergen immunotherapy, anti-IgE treatment. Lastly, they state that when considering the natural resolution of food allergy, the BAT may be able to reduce the number of oral food challenges, because it has better predictive value compared to skin testing or in vitro testing.

4. Clinical contraindications to allergen immunotherapy: an EAACI position paper

Pitsios C, Demoly P, Bilo MB, Gerth van Wijk R, Pfaar O et al. Clinical contraindications to allergen immunotherapy: an EAACI position paper. European Journal of Allergy and Clinical Immunology 2015; 70(8): 897-909. (doi:10.1111/all.12638).

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This document was assembled by a task force of the European Academy of Allergy and Clinical Immunology (EAACI) to examine the literature regarding contraindications of immunotherapy. They developed recommendations regarding the use of immunotherapy to aeroallergens as well as venom in patients with cardiac disease, autoimmune disease, immune deficiency as well as those requiring ACE inhibitors, Beta blockers, and MAO inhibitors. This is a very useful document for practicing allergists performing immunotherapy.

5. Vaccination in patients with primary immune deficiency, secondary immune deficiency and autoimmunity with immune regulatory abnormalities

Eibl MM, Wolf HM. Vaccination in patients with primary immune deficiency, secondary immune deficiency and autoimmunity with immune regulatory abnormalities. Immunotherapy 2015; posted online ahead of print, 20 August. (doi:10.2217/IMT.15.74)

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This comprehensive review examines the literature regarding vaccination of patients with both primary and secondary immune deficiency. This document includes two excellent tables that provide an easy reference for clinicians regarding appropriate and safe vaccination.