4 APAPARI workshop foodallergy en (1)

2017 APAPARI Workshop in Hanoi What’s New in Food Allergy? Takao Fujisawa, MD PhD Allergy Center and Institute for Clinical Research Mie National Hospital JAPAN Food allergy is increasing in the world A survey in 2012 by World Allergy Organization (W AO) showed that the vast majority of countries rep orted an increase in food allergy prevalence in food the OFC proven allergy preceding 10 years in preschool children 10% in Europe, 7% in China Prescott SL A global survey of changing patterns of food allergy burden in children World Allergy Food allergy is on the rise • Prevalence of self-reported peanut or tree nut allergy increased more than 3-fold from 1997 to 2008 （ USA) • • Sicherer SH Us prevalence of self-reported peanut, tree nut, and sesame allergy: 11-year follow-up J Allergy Clin Immunol 2010;125:1322-1326 Retrospective analysis of referred children to allergy specialists; 4-fold increase from 1995 to 2005 （ Australia) • Mullins RJ Paediatric food allergy trends in a community-based specialist allergy practice, 1995-2006 The Medical journal of Australia 2007;186:618-621 Food allergy is on the rise School survey in Japan (Ministry of Education and Science, Japan) 2007 Food allergy Anaphylaxis Elementary (7-12y) Junior high (1315y) High (16-18 y) Total 2013 Food allergy Anaphylaxis Epipen® holders Elementary (7-12y) Junior high (1315y) High (16-18 y) Total http://www.mext.go.jp/b_menu/houdou/25/12/1342460.htm A paradigm shift What’s New in Food Allergy? Prevention of food allergy To prevent food allergy… Maternal avoidance of allergenic food To prevent food allergy… Maternal avoidance of allergenic food did not prevent de velopment of allergic diseases and food sensitization Egg sensitization (18month ） Milk sensitization (18month ） Kramer MS, Kakuma R Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating To prevent food allergy… Maternal avoidance of allergenic food did not prevent de velopment of allergic diseases and food sensitization estational weight gain Birthweight Kramer MS, Kakuma R Maternal dietary antigen avoidance during pregnancy or lactation, or both, for preventing or treating To prevent food allergy… The EP does not recommend restricting maternal diet during pregnancy or lactation as a strategy for preventing the development or clinical course of FA Boyce Guidelines for the Diagnosis and Management of Food Allergy in the United States: Summary of the NIAID-Sponsored Expert Panel Report J Allergy Clin Immunol 2010; 126:1105-18 To prevent food allergy… Old recommendation • Solid foods should not be introduced into the diet of highrisk infants until months of age, with dairy products delayed until year, eggs until years, and peanuts, nuts, and fish until years of age • American Academy of Pediatrics Committee on Nutrition Hypoallergenic infant formulas Pediatrics 2000; 106:346-9 Resulting in Oral food challenge Objectives Determination of the safe intake quantit y and judgement of tolerance acquisitio n Determination of the safe intake quantity (Small t o medium dose) Judgement of tolerance acquisition (Full dose) Ebisawa M, Ito K, Fujisawa T, Japanese guidelines for food allergy 2017 Allergol Int 2017; 66: Oral food challenge Methods Total challenge dose Administration intervals Ebisawa M, Ito K, Fujisawa T, Japanese guidelines for food allergy 2017 Allergol Int 2017; 66: What’s New in Food Allergy Management Management of food allergy Avoidance of allergenic food Oral food challenge “Necessity minimum”, based on correct diagnosis Diet for food allergy patients should, be Safe :No allergy symptoms including anaphylaxis caused by “accidental “ingestion of offending food contain necessary nutrition for growth Not impair quality of life Proper and prompt treatment for allergen- ind uced symptoms, especially anaphylaxis Self injection of adrenalin (Epipen®) Education of patients, families and schools Necessity minimum strong Allergenicity weak weak Heat processing Strong Raw Lightly scramble d pudding Scrambled Pancake cookies Mayonnaise Omelet Donut Fried chicken Boiled Boiled 12 Boiled 30 How much milk in there ） Butter ml Yakult Sliced ham Bread ml 10 ml Milk role bread 30 ml 30 ml Sliced cheese Pizza >200 ml 100 ml Anaphylaxis ） WAO guidelines Simons FE World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis Anaphylaxis ） WAO guidelines Simons FE World Allergy Organization Guidelines for the Assessment and Management of Anaphylaxis Adrenaline (epinephrine) is the first choice for anphylaxi s Simons FE First-aid treatment of anaphylaxis to food: focus on epinephrine J Allergy Clin Immunol 2004; 113:837-44 What’s New in Food Allergy Oral immunotherapy Oral immunotherapy (OI T) OIT is defined as a treatment method for c ases where the early acquisition of toleran ce during the natural course cannot be anti cipated After a symptom induction threshold has b een determined by OFC, causative foods ar e taken under a physician's instruction aim ing to acquire the conditions of increased t hreshold or desensitization The therapy is ultimately aimed at acquirin g tolerance to the causative foods Ebisawa M, Ito K, Fujisawa T, Japanese guidelines for food allergy 2017 Allergol Int 2017; 66: OIT protocol Maintenanc Rush build-up (in hospital) e dose (at home) whole egg OFC Threshold 1/10 start day OFC threshold Itoh-Nagato N, Inoue Y, Nagao M, Fujisawa T, Shimojo N, Iwata T Desensitization to a Whole Egg by Rush Oral Immunotherapy Improves Quality of Life of Guardians: A Multicenter, Randomized, Parallel-Group, Delayed-Start OFC after >2w re-elimination diet 18 cases (47.3%) 1000 13 cases (34.2%) 800 600 400 Maintained desensitization levels Reduced desensitization levels Induced symptoms, sometimes anaphylaxis, are unavoidable during OIT 4cases (15.8%) Lost 200 cases desentization levels 12 M 2M e Pr Unheated egg powder (mg) >1000 maintenance period Itoh-Nagato N, Inoue Y, Nagao M, Fujisawa T, Shimojo N, Iwata T Summary Food allergy diagnosis Detailed clinical history =the most important Clinical classification Careful interpretation of IgE tests Oral food challenge=gold standard Management of food allergy Necessity minimum elimination diet Safe Maintain QOL Oral Immunotherapy Effective but still at investigational