Literature review - Twitter summary from #ACAAI18 meeting

Literature review – Twitter summary from #ACAAI18 meeting


Therapy with protease inhibitors (alfa-1-antitrypsin) could also be helpful in EoE .

SPINK7 (a serine protease inhibitor) was decreased in biopsies from EoE sufferers. Discount of SPINK7 led to epithelial cell disruption and elevated inflammatory cytokine manufacturing. Serine protease inhibitors MAY be a therapy for EoE.

TH2A cells

TH2A cells have been recognized in atopic people and cut back with immunotherapy. TH2A cells might be used as atopic illness biomarkers and a attainable therapeutic goal. TH2A cells: the way forward for atopic markers together with CRTH2, CD161, and CD49d, with low expression of CD45RB and CD27. TH2A cells are CD4+, CD45RB low,, CD49d+, CRTH2+, CD27-, CD161+. They will produce IL-4, 5, 9, 13.


Pulmonary neuroendocrine cells (PNECs) are potential essential cells for goal in bronchial asthma thought down regulation of ILC2’s cells . PNEC (Pulmonary Neuroendocrine Cells) are lung cells that are elevated in sufferers with bronchial asthma. PNEC improve Il-2 exercise and Goblet cell metaplasia by means of GABA. Might PNEC be a great goal for bronchial asthma therapy sooner or later?

IL-33 results in launch of ILC2 precursors from the bone marrow. Alternaria (direct stimulation) and Aspergillosis (although IL-33 gene cleavage) might enhance ILC2’s although estimation of IL-33.


Dr. Routes MD with an replace on Scientific Immunology: NFKB1: learn a evaluate in Cell 168:37-57,2017

It seems NFKb mutation is the one most typical monogenic reason behind CVID.

NFKB1: 16 pathogenic mutations, uncommon and restricted to CVID, autosomal dominant with 60% penetrant ; lower reminiscence switched B cells; enhance CD21 low B cells. Decreased switched reminiscence B cells are key in PID and autoinflammatory issues no matter IgG stage. Most of the hyperlinks are through NFKb.

Decreased NFKB1 phenotypes (AD, 60% penetrant): aphthous ulcers, Behcet-like and hypog (H67R); inflammatory GI tract illness and hypogam (I553M); NO hypogam, decreased switched B cells, necrotizing cellulitis (R157X).

APDS1: sinopulmonary infections, LAN/splenomegaly, bronchiectasis/bronchitis/tracheal nodules, EBV/CMV, HSV, VZV infections; Excessive IgM, IgM+ however not IgG+ B cells in tissue.

CGD carriers can get illness like CGD lite, particularly if DHR positivity is under 20%. CGD provider: practically 50% had infections and inflammatory illness; DHR check between 20-80%, if lower than 20% begin prophylaxis with TMP/SMX. X-CGD carriers have elevated threat of infections and/or autoimmune manifestations (AIM). Discoid lupus is a typical AIM. Sufferers with irregular DHR assay (under 20%) might be thought of for TMP/sulfa prophylaxis.

Display screen & deal with moms, sisters of Power Granulomatous Illness sufferers as carriers at excessive threat of autoimmune & an infection.

BMT can enhance survival in scleroderma.

Bronchial asthma

Dr. Li on bronchial asthma and decrease respiratory ailments. Dupilumab was more practical for bronchial asthma if eosinophils have been larger than 300. Eosinophilia can happen in 4.1% and hypereosinophilia 1.2% on dupilumab for bronchial asthma. Elevated FeNO predicted higher response to dupilumab.

Dupilumab just lately accredited for moderate-severe bronchial asthma: if eosinophils are increased than 300 or FeNO is elevated, see higher response to therapy with this biologic. Hypereosinophilia complication in 1.2% , eosinophilia seen in 4% of sufferers.

Dupilumab in mod-to-sev bronchial asthma: reduces bronchial asthma exacerbation price (0.46 vs 0.87) and elevated FEV1 (0.32 vs 0.14 L); eosinophilia/hypereo was reported as an AE Corren et al NEJM.

As wanted budesonide-formoterol vs upkeep budesonide in gentle bronchial asthma: exacerbations – no distinction; FEV1 and symptom management – maint budesonide higher. As wanted budesonide-formoterol was not totally different from budesonide-formoterol BID in bronchial asthma exacerbation price. Corticosteroid load was decrease within the as wanted group however symptom management and FEV1 have been higher with BID. Bateman et al NEJM. Dr Li: there may be some proof for sufferers to make use of as wanted budesonide-formoterol slightly than twice a day.

Quadrupling inhaled corticosteroids decreased the time to first bronchial asthma exacerbation in an unblinded, randomized trial by McKeever et al (NEJM). Quadrupling ICS early in bronchial asthma exacerbation is an efficient technique. Nevertheless there was a companion paper that confirmed totally different outcomes when blinded. Quadrupling ICS to abort bronchial asthma exacerbations: Appear to work — hazard ratio 0.81 (0.71-0.92) in favor; NNT 15.

Jackson in JAMA 2018: even 5x enhance Inhaled steroid dose in yellow zone didn’t stop exacerbations in kids with bronchial asthma – would possibly impression progress. So….What can we do with our bronchial asthma motion plans?

RIsk elements for extreme bronchial asthma: older, increased BMI, larger smoking historical past, decrease lung operate, decrease ACT scores. Extreme bronchial asthma in Sweden by questionnaire: 1.3% of the cohort, 36% of surveyed confirmed at the very least one signal of bronchial asthma severity.

Extreme bronchial asthma is extra frequent than you would possibly suppose: massive examine in Sweden exhibits 36% with indicators of extreme bronchial asthma. Sufferers extra extreme have been older, had increased BMI, increased price of smoking historical past, increased symptom scores. Hyperlink:

TENOR II examine: affected person reported outcomes; excessive diploma of co-morbid circumstances.

For persistent cough clinic: FeNO not useful for eosinophilic bronchitis however has a possible for cough variant bronchial asthma. FeNO not helpful for eosinophilic bronchitis, however it does have utility in cough variant bronchial asthma. Cough variant #bronchial asthma has at all times been a scientific prognosis. Can we now use FeNO as a diagnostic check? How might this alteration our apply / affected person expertise? Hyperlink:

Eosinophilia in COPD above 300 linked to elevated threat of COPD exacerbation. COPD mortality is far larger than bronchial asthma mortality. COPD mortality is rising whereas bronchial asthma mortality is lowering.


Dr. Riedl on urticaria, angioedema, and different pores and skin issues. IL-24 particular IgE is current in CIU sufferers. This correlates with signs, ie increased anti IL-24 IgE results in worse signs.

Sufferers with persistent spontaneous urticaria (CSU) have IgE to a large variety of autoantigens together with IL-24. As many as 80% of pts w CSU have excessive ranges of IgE-anti-IL-24 and these ranges correlate w illness exercise. Schmetzer et al, JACI.

CSU: 80% of sufferers have elevated IgE anti — IL-24 which set off MC degranulation; unknown relevance of this discovering for CSU. There may be additionally IgE to different auto antigens.

Lastly elucidating some prospects for particular autoimmune mechanisms of Power Spontaneous #Urticaria. Might this counsel attainable future testing for refractory instances? Will it drive extra particular biologic therapies? Hyperlink:

Increased dose of Omalizumab (600 mg This autumn Weeks) improves management of CSU. Predictors of upper doses of omalizumab was increased BMI and age. Updosing of omalizumab to 450-600 mg each Four weeks for CSU not managed with common dosing: achieved 93% management; significantly in sufferers with increased BMI and older age.

JAMA Derm 2017 Decision price of persistent #urticaria in kids is low and CU can go on for months or years, 57% proof of autoimmune trigger – Basophil activation check constructive. Constructive BAT really good as predictor of earlier decision.


Montelukast helps angioedema predominant UAS. Leukotrienes might need a extra essential function within the pathogenesis of angioedema than CSU (urticaria alone or urticaria/angioedema). Montelukast (LTRA) reduces symptom severity and frequency in sufferers with angioedema-predominant CSU handled with Four x labeled dose antihistamine with out using omalizumab – be careful for nightmares from LTRA. The report is from a single middle retrospective trial. In angioedema solely sufferers bradykinin mediated illness could also be recognized by a plasma kallikrein check. Hopefully a brand new biomarker?

Histamine vs bradykinin induced angioedema: threshold-stimulated kallikrein; excessive specificity and constructive chance ratio for bradykinin-mediated angioedema. Dr. Marc Reidl: We positively want higher biomarkers for elucidating histamine v. Bradykinin mediated angioedema – might Threshold-stimulated kallikrein exercise assay be a helpful new check?


There could also be an oral Plasma Kallikrein coming to deal with HAE. Very useful in non GI assaults. Oral plasma kallikrein inhibitor (BCX7353) for prophylaxis in HAE section II examine: 125 mg dose or extra resulted in a considerably decrease price of assaults in comparison with placebo; GI unwanted effects and LFT elevation at increased doses.

Eye-opening knowledge, evaluate of 70 HAE deaths confirmed 63 of these sufferers had no HAE prognosis at time of demise, regardless of household historical past of HAE. The at all times essential reinforcement, by Dr. Marc Riedl, that each HAE assault is materials for on-demand therapies and that these sufferers needs to be thought of for prophylactic therapies at each workplace go to. Tremendous helpful desk by Dr. Riedl on present HAE therapies. No much less essential is the hassle that’s being positioned on coaching for self-administration at residence:


Allergy to HDM will increase threat of IgE to staph and E. Coli. Atopic dermatitis: IgE reactivation to bacterial antigens is extra frequent in sufferers with HDM vs non HDM sensitization.

Promising examine of average AD and probiotics: improved within the SCORAD index with using Bifidobacterium lactis (CECT 8145;7347;9104). AD and probiotics: an NIH examine exhibiting some enchancment with using Roseomonas mucosa although topical software.
Promising probiotics in AD: topical Roseomonas mucosa and PO particular Bifidobacterium lactis (CECT 8145;7347;9104) – there’s a want for extra research.


Human microbiome: Three lbs, 100 trillion cells – what got here first the biome or the atopy? Eosinophilia lung irritation correlates with decrease airway bacterial variety that embrace extra pathogenic micro organism. Presence of Haemophilus within the lung was an indicator of poor response to Fluticasone.

There could also be modifications of the intestine microbiome in CU. Intestine microbiome might even play a task in persistent urticaria and level to attainable interventions.

Updates on anaphylaxis, drug allergy and stinging insect hypersensitivity

Delayed recognition, inappropriate therapy of anaphylaxis resulting in lawsuits. Although no allergists listed as defendants, we should nonetheless take duty for educating our colleagues and main techniques enhancements in our establishments. There are such a lot of challenges with Epi auto injectors from correct dosing to sufficient needle size to price. It’s advised primarily based on splendid dose that switching from 0.15 to 0.30 epi ought to happen at 20-25 Kg not 30 as is present apply.

Dr. Montanaro: “Amoxicillin allergy is completely over identified and prognosis is never confirmed.” A really often used antibiotic. We must always attempt to alway affirm or discard the prognosis by means of the suitable exams. Bear in mind Drug Provocation Check is GOLD STANDARD.

One other reversal from #ACAAI18: Serum tryptase not very useful in assessing anaphylaxis threat for venom.


Seasonal lower in IT dose in season doesn’t change share of reactions to IT.

Discussing IT for native allergic rhinitis is fascinating for proof of idea however unimaginable to do in a neighborhood apply and mucous IgE testing or nasal allergen problem aren’t obtainable.

It is a Twitter abstract from #ACAAI18 assembly primarily based on tweets by the next allergists:
@WAOJM @Ismallergy @alexeigonzmd @DocAllergy @AllergyHealth @JPLopesMD

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