Update: Role of Sublingual Immunotherapy in the Treatment of
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Transcript Update: Role of Sublingual Immunotherapy in the Treatment of
Advanced Topics in
Sublingual Immunotherapy
Diagnostics & Delivery
George F. Kroker, MD FACAAI
Case Report
J.L. was a 26 year old graduate student
at U of Penn who presented in Oct
2009 with the recent diagnosis of
eosinophilic esophagitis and
recalcitrant dysphagia unimproved on a
strict elimination diet
Copyright 2015 Allergy Associates of La Crosse
Past Medical History
As infant, suffered from chronic
dermatitis affecting back of knees, trunk
Trouble on introducing solids with
vomiting—extended breast feeding
By age 2, recurrent o.m. with pe tubes
As child, vomiting from restaurant food,
especially Chinese food
Copyright 2015 Allergy Associates of La Crosse
Past Medical History (cont.)
Chronic vaginal rashes
Asthma beginning in 1st grade
Worse in elementary school
Saw allergist—told allergic to peanuts,
tree nuts, weeds, grasses, trees, mite,
cats
Took SCIT for a few years
Copyright 2015 Allergy Associates of La Crosse
Past Medical History (Cont.)
In 2002 severe reaction to nut ingestion
over holidays; required ER treatment
In 2004 severe reaction to Mango lassi
2007 began experiencing constant
heartburn unresolved with OTC Rx
Began graduate school, periods of
feeling as if “swallowing broken glass”
Copyright 2015 Allergy Associates of La Crosse
Past Medical History (cont.)
2007 Endoscopy revealed 12 eos/HPF
No dx EoE, given Nexium
Sudden crisis July 4th weekend, 2009:
At
holiday cottage, no air conditioning
Had cottage cheese dip with raw celery
and had immediate severe dysphagia
Copyright 2015 Allergy Associates of La Crosse
Past Medical History (cont.)
Repeat Endoscopy 2009
Eosinophilic Esophagitis confirmed
>20
Eos/HPF mid esophagus
15-20 Eos/HPF proximal esophagus
Rx Flovent swallowed; allergy consult
Copyright 2015 Allergy Associates of La Crosse
Allergy Testing 2009
Food/Inhalant
Result (kU/L)
Beef
<.35
Casein
.56
Chicken
<.35
Chocolate
.76
Corn
1.84
Egg white
<.35
Milk
.74
Orange
.47
Peanut
2.04
Potato
.70
Rice
1.60
Copyright 2015 Allergy Associates of La Crosse
Allergy Testing 2009
Food/Inhalant
Result (kU/L)
Soybean
2.63
Tomato
1.50
Wheat
1.34
Pork
<.35
Tuna
<.35
Banana
1.04
Apple
1.48
Turkey
<.35
Copyright 2015 Allergy Associates of La Crosse
Allergy Testing 2009
Food/Inhalant
Result (kU/L)
Almond
<.35
Brazil nut
1.30
Coconut
<.35
Pecan
2.45
Sesame seeds
7.09
Cashew
1.99
Walnut
1.47
Pistaschio
3.14
Pine Nut
<.35
Clam
2.04
Crab
3.70
Copyright 2015 Allergy Associates of La Crosse
Allergy Testing 2009
Food/Inhalant
Result (kU/L)
Lobster
4.13
Oyster
2.29
Shrimp
4.68
Blue Mussel
1.91
Scallops
1.69
Crayfish
4.27
Cucumber
0.69
Grape
<.35
Oat
2.43
Quinoa
1.89
Copyright 2015 Allergy Associates of La Crosse
Allergy Recommendation: 2009
“Eliminate the following foods from your
diet for 90 days: soy, carrot, peas,
beans, legumes, peanut, celery,
sesame, milk, corn, rice, wheat, tomato,
tree nuts shellfish. Then repeat
endoscopy”.
Copyright 2015 Allergy Associates of La Crosse
Case Presentation (cont.)
On strict elimination diet patient felt no
improvement in dysphagia
Other symptoms present:
Fluctuating
upper respiratory congestion
Migratory pruritic skin rashes
Episodic diarrhea
SOB with exercise
No definite pollen-food oral symptoms
Copyright 2015 Allergy Associates of La Crosse
Case Presentation (cont.)
Medications:
Prilosec
Zoloft
Yaz
Oral Contraceptive
OTC antihistamine prn
Physical Exam
No
urticarial, angioedema, wheezing
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Patient Concerns
Why am I not getting better when I’m
avoiding so many food allergens?
How can I possibly be sensitive to so
many items, and how can I treat them?
I’m confused and discouraged…
……..please
Copyright 2015 Allergy Associates of La Crosse
help me
The Total Load Concept
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Case Presentation: Blood tests
Vitamin D 28.9
CBC wnl; hb 13.6, hct 42, WBC 4900
No
eosinophilia
Serum iron 131 wnl
AST 14, wnl
Copyright 2015 Allergy Associates of La Crosse
Intradermal Skin Testing
Antigen
Mm diameter
Dilution #
Dust Mite Mix
18
3
Ragweed
16
5
Grass
15
5
Dog
10
4
Alternaria
11
4
8
3
Aspergillus
13
3
Penicillium
10
3
Candida
12
2
Histamine Control 10
2
Cladosoporium
Copyright 2015 Allergy Associates of La Crosse
IgE ELISA
Antigen
Conc IU/ml
Class
Dust Mite Mix
9.50
IV
Baker’s Yeast
1.96
III
Grass
(Kentucky/June)
13.82
V
Candida albicans
3.40
IV
Alternaria
16.21
V
Copyright 2015 Allergy Associates of La Crosse
Phadia Component Testing—
Positive Results
Allergen
Component
Classification
Birch
rBetv1
PR-10
Celery
rApi g 1
PR-10
Carrot
rDau c 1
PR-10
Apple
rMal d 1
PR-10
Peach
rPru p 1
PR-10
Peanut
rAra h 8
PR-10
Soybean
rGly m4
PR-10
Shrimp
rPen a 1
Tropomysin
Dust Mite
rDer p 10
Tropomysin
Copyright 2015 Allergy Associates of La Crosse
Time
Working Medical Hypothesis
Chronic
Dermatitis
Dairy/soy allergic
infancy
Pollen food
Cross-rxns
Inhalant allergies
“atopic march”
Increased
Intestinal Permeability
Secondary food
Allergies
Lower GI Tract
Eosinophilic
Esophagitis
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Recurrent
Otitis Media
asthma
Recurrent
Antibiotics
Intestinal
Dysbiosis
Reassurance
Hope
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Patient Presentation: SLIT
Priorities in Treatment
Inhalants (can’t control exposure)
Super-Antigens
(Birch, Ragweed) due to
pollen—food connection
Perennial allergens—dust, molds
Foods hard to avoid—grains, dairy,
legumes/soy
Foods easier to avoid—nuts, shellfish
(Rxns
from Total Allergy Load)
Copyright 2015 Allergy Associates of La Crosse
Sublingual Testing at #7
Dilution
Antigen
Result
Corn
Itchy throat
Milk
Itchy throat
Soy
unchanged
Tomato
unchanged
Rice
unchanged
Wheat
Tight chest
Copyright 2015 Allergy Associates of La Crosse
Diet strategy in Patient
RDD for patient avoided milk, soy,
wheat, corn, orange, chocolate, peanut,
tree nuts & seeds for 6 months
Gradually converted to “modified”
rotation (“zone approach”)
“red
zone” avoid
“yellow zone” proceed with caution! Rotate
“green zone” eat freely
Copyright 2015 Allergy Associates of La Crosse
Case Presentation (cont)
Treatment
Environ control
SLIT inhalants
SLIT foods
Rotation Diet
Fluconazole
Probiotics
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Strategy
Lower dust/pollen load
Help dysphagia
Help food tolerance
Minimize new food
sensitivities short term
Lower Candida, help GI
tract heal
Help GI tract heal
Case Presentation (cont)
Treatment
Strategy
Zyrtec D
Flovent Orally
Gastrocrom before
Help congestion
Prn EoE exacerbation
Minimize risk of
restaurant meals
ProAir available
Vitamin D, multiple
vitamin replacement
Copyright 2015 Allergy Associates of La Crosse
reaction eating out
At risk for EIA
Aid in immune
modulatioin
SLIT Strategy in Patient:
inhalants
Use threshold dosing for inhalants
Use ½ bottles of antigens
Establish priorities in inhalant treatment
Superantigens
Perennial
antigens
Every 6 weeks, increase inhalants by 1
(or fraction of 1) dilution on “out of
season” allergens
Copyright 2015 Allergy Associates of La Crosse
SLIT Strategy in Patient: foods
Use dosing based on ELISA
Use ½ bottles of antigens
Establish priorities in food treatment
Add 3-5 new foods to each new bottle
For PR-10 allergy, don’t need to add
these foods, Rx inhalant superantigen
Copyright 2015 Allergy Associates of La Crosse
Reaction = sensitivity x load
Reduce sensitivity:
Use SLIT
Dilution #
1
2
3
Dust
Dust Mite—
Dust mite barrier covers
Pollen
Mold
Pollen & Mold-Use Air Conditioning
Foods
Food Allergens—
Follow Hypoallergenic Diet
Candida
Candida—
Fluconazole, Diet
4
5
6 wks
Copyright 2015 Allergy Associates of La Crosse
Reduce load
Patient Progress—Jan 2010
October 2009—treatment begun
Reduced dysphagia
More energy
Diarrhea gone
Breathing easier
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Patient Progress—April 2010
Only one episode of dysphagia:
Tested chocolate brownie—immediate
pain between shoulder blades, fatigue
Compliant with diet, treatment
Copyright 2015 Allergy Associates of La Crosse
Patient Progress—Dec 2010
No further dysphagia
As baseline improved, patient realized
most reactive to wheat, chocolate
Tried wheat/chocolate without
gastrocrom and ok with small
amounts
Compliant with diet, treatment
Copyright 2015 Allergy Associates of La Crosse
Patient Progress—July 2011
No further dysphagia
Mild spring SAR during grass season
Chocolate continues to cause fatigue
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Patient Progress—Dec 2011
Dysphagia/EoE flare up
Occurred when ate former allergens
consecutively over weekend at
boyfriends house
Boyfriend had cat
Cat test positive: 13 mm Dil#5
Copyright 2015 Allergy Associates of La Crosse
Patient Progress—July 2013
No dysphagia
All foods tolerated ad lib except for
nuts, soy, wheat and chocolate
Spring grass season went well
Copyright 2015 Allergy Associates of La Crosse
Patient Progress—May 2014
Excellent Grass season; no flare-ups
Vitamin d level rechecked; 42.8
No dysphagia
Reviewed diet with patient:
Red
zone—wheat, sugar, nuts, shellfish
Yellow zone—soy, corn, dairy
Green foods—all others
Copyright 2015 Allergy Associates of La Crosse
Patient Presentation—May 2014
Energy, quality of life have returned
Married in July!
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Patient Presentation—Nov 2014
Got married—able to eat wedding cake!
Traveled to Mexico, did fine with food
Mild ear plugging in fall, otherwise ok
Endpoints found for nuts by challenge:
Cashew #9—itching lip; #10 ok
Sesame #9 ok
Peanut #9 ok
Walnut #9 ok
Endpoints found for shellfish/mollusk by challenge
Shrimp #9 fatigue; #10 ok
Scallop #9 ok
Copyright 2015 Allergy Associates of La Crosse
Beginning to Current
Inhalant Treatment
2009
2014
Multi-Inhalants
TX
Dilution
TX
Dilution
Mite
5
3
Ragweed
5
1
Grass Mix
5
1
Birch
5
1
Tree Mix
5
1
Alternaria
5
2
Copyright 2015 Allergy Associates of La Crosse
Beginning to Current
Food Treatment
2009
2014
Food
TX
Dilution
TX
Dilution
Corn
6
1
Milk
6
1
Soy
5
1
Tomato
5
1
Rice
4
1
Wheat
4
1
Chocolate
4
1
Yeast
5
3
Egg
4
2
Chicken
3
2
Copyright 2015 Allergy Associates of La Crosse
Key Points from Case Study re:
Eosinophilic Esophagitis
Food sensitivity AND inhalant allergy may
BOTH play a role in triggering EoE
Clinical correlation needs to be made when
Eos/HPF elevated but not diagnostic
Don’t ignore non-esophageal symptoms in
EoE pt! Other target organs may be involved
“Food-Pollen Syndrome” may involve
Esophagus
Copyright 2015 Allergy Associates of La Crosse
Key Points from Case Study re:
The Pan-Allergic Patient
A thorough, chronological history is
essential
Total load concept explains history!
Pan-allergic patients may be
successfully treated with SLIT
Establish
treatment priorities
Use threshold dosing
Frequent incremental changes
Copyright 2015 Allergy Associates of La Crosse
Thank you
Next:
Lessons Learned in 35 Years of
Experience
George Kroker MD
Copyright 2015 Allergy Associates of La Crosse