Allergy diagnosis for inhalant immunotherapy Stephen R Durham (acknowledges Arif Eifan) Allergy and Clinical Immunology Imperial College London and Royal Brompton Hospital . s.durham@imperial.ac.uk March 15th 2018 EAACI, Dubrovnic

Disclosure In relation to this presentation, I declare the following, real or perceived conflicts of interest: Type Company Employment full time / part time None Spouse / Family member employment / engagement Research Grant (P.I., collaborator or consultant; pending and received grants) ALK, Biotech Tools, Regeneron USA Other research support MRC UK, Food Standards Agency UK, Immune Tolerance Network/NIAID USA Speakers Bureau / Honoraria PneumoUpdate GmbH, Allergy Therapeutics Ownership interest (stock, stock-options, patent or intellectual property) Consultant / advisory board ALK, Adigo, Anergis, Biomay, GSK UCB

Use of Molecular based Allergy Diagnostic Testing Allows patients’ sensitization profiles to be characterized in greater detail Verifying a genuine primary sensitization Differentiate between true symptoms and symptoms due to cross‐reactivity May assess the clinical risk for reactions (both mild and severe) May help select patients for food challenge and May help select patients for targeted immunotherapy

Molecular diagnosis in inhalant and venom immunotherapy Current diagnosis and selection criteria for SIT Major allergens for immunotherapy Primary sensitisation v cross reactivity How may molecular diagnosis help select patients for immunotherapy

Molecular diagnosis in inhalant and venom immunotherapy Current diagnosis and selection criteria for SIT Major allergens for immunotherapy Primary sensitisation v cross reactivity How may molecular diagnosis help select patients for immunotherapy

Current selection of patients for targeted immunotherapy Clinical history of symptoms on exposure Skin prick test: whole allergen extract 3. Allergen specific IgE: whole allergen extract

SPT to common inhaled allergens

Use of Skin Prick Tests Diagnosis of atopy Supportive evidence (positive or negative) for clinical history Essential if avoidance measures are being considered Educational value: visual reinforcement of verbal advice

Patient selection for allergen immunotherapy Indications Contra-indications Rhinoconjunctivitis with/without mild asthma Symptoms on exposure to relevant allergen IgE sensitisation to relevant allergen (SPT and /or Sp-IgE) Inadequate response to anti-allergic drugs Unacceptable drug side effects Polysensitisation not a contra-indication Moderate-severe asthma Multiple allergies Severe side effects with SCIT Autoimmune/Immunodeficiency disorders Malignancy Pregnancy (continue maintenance SLIT OK) Lack of understanding, poor adherence to treatment

Case report. Mrs AC, 46yrs management consultant: Hayfever for 20 years during May-August Nasal itch / sneezing and congestion Watery discharge (nose plugged with tissues) Itchy, red eyes Poor response to nasal steroids, antihistamines Concerned about drug side effects Unable to cycle, do gardening, play with son Poor concentration, tiredness, impaired work Busy lifestyle, unable to attend for monthly injections

Mrs AC, 46 yrs SPT +ive (7mm) to grass pollen No perennial symptoms, other SPTs –ive No asthma symptoms, normal spirometry Nasal mucosa appeared normal Diagnosis: Severe grass pollen hayfever with impaired quality of life, unresponsive to medical treatment

Sublingual immunotherapy Grass allergy tablet sublingual immunotherapy Dec – August Daily tablet Itching under the tongue, resolved after 10 min, not troublesome. During Summer (severe pollen season), AC had only mild symptoms, used minimal reliever medication and was able to perform gardening and rejoined her cycle club.

Symptom scores before/after SLIT

“Compared to your hayfever symptoms in previous grass pollen seasons, how have you felt overall this season?” Much better Yes Better - The same Worse Much worse

Molecular diagnosis in inhalant and venom immunotherapy Current diagnosis and selection criteria for SIT Major allergens for immunotherapy Primary sensitisation v cross reactivity How may molecular diagnosis help select patients for immunotherapy

Defining allergens that ‘make a difference’ ALLERGEN NOMENCLATURE: WHO/IUIS Allergen Nomenclature Sub-Committee Breiteneder H, et al. Allergen Nomenclature. 2014, pp 37-49.

Defining allergens that ‘make a difference’ Examples of allergens and their sources that fulfill most of these criteria Breiteneder H, et al. Allergen Nomenclature. 2014, pp 37-49.

Molecular diagnosis in inhalant and venom immunotherapy Current diagnosis and selection criteria for SIT Major allergens for immunotherapy Primary sensitisation v cross reactivity How may molecular diagnosis help select patients for immunotherapy

Primary sensitization Der p 1, Der p 2, Der f 1, Der f 2, Der p 23 Allergen Components - cross reactivity Pollens Primary sensitization Cross-reactivity Ragweed Amb a 1 Mugwort Art v 1, Art v 3 Art v 3 Parietaria Par j 2 Plantain or Ribwort Pla l 1 Timothy Phl p 1, Phl p 5, Phl p 6 Phl p 4, Phl p 7, Phl p 11, Phl p 12 Bermuda grass Cyn d 1 Birch Bet v 1, Bet v 6 Bet v 1, Bet v 2, Bet v 4 Bee Api m 1, Api m 4 CCDs Wasp Pol d 5, Ves v 1, 5 Ves v 2, CCDs House dust mite Der p 1, Der p 2, Der f 1, Der f 2, Der p 23 Der p 10

Allergen Components - cross reactivity Protein families Characteristics Allergens PR-10 Heat-labile proteins- Cooked foods tolerated. Bet v 1 homologues - OAS Bet v 1, Ara h 8, Gly m 4, Cor a 1, Mal d 1 Profilins Minor allergens rarely cause symptoms, but severe reactions in minority of patients. Sensitization to profilin may give rise to positivity to pollen extracts, however this has low clinical relevance in most cases Bet v 2 Pru p 4 Mal d 4 Phl p 12 CCD A marker for sensitization to protein carbohydrate moieties (pollen, hymenoptera). Seldom associated with clinical symptoms, but may cause adverse reactions in a limited number of patients CCD;MuxF3 Ana c 2 Procalcin (Calcium-binding proteins) Highly cross-reactive, proteins present in most pollens, but not in plant foods Bet v 4, Phl p 7 Tropomyosins Actin-binding proteins in muscle fibres. Used as a marker for cross-reactivity between crustaceans, mites, cockroach and nematodes Pen m 1 (shrimp), Der p 10 (HDM), Ani s 3

Molecular diagnosis in inhalant and venom immunotherapy Current diagnosis and selection criteria for SIT Major allergens for immunotherapy Primary sensitisation v cross reactivity How may molecular diagnosis help select patients for immunotherapy

3 patients with symptoms in UK in April-May and a positive SPT/IgE to whole grass and birch pollen extracts Patient 1: Specific-IgE Phl p 1 Phl p 5 Phl p 12 Patient 2: Specific-IgE Phl p 1 Phl p 5 Bet v 1 Patient 3: Specific-IgE Bet v 1 Bet v 2

3 patients with symptoms in UK in April-May and a positive SPT/IgE to whole grass and birch pollen extracts Patient 1: Grass pollen SAR Specific-IgE Phl p 1 Phl p 5 Phl p 12 (Bet v 2) Patient 2: Grass and birch SAR Specific-IgE Phl p 1 Phl p 5 Bet v 1 Patient 3: Birch pollen SAR Specific-IgE Bet v 1 Bet v 2 (Phl p 12)

AIT and Grass pollen allergy

Impact of IgE-sensitivity to profilins and other cross-reacting molecules on immunotherapy prescription J J Allergy Clin Immunol 2014;134: 78- 2525

Impact of IgE-sensitivity to profilins and other cross-reacting molecules on immunotherapy prescription Children (n=651) with moderate-to-severe pollen related AR were recruited SPT to grass, cypress, olive, mugwort, pellitory, and/or Betulaceae extract IgE to Phl p 1, 5, Phl p 7 (procalcin) 12 (profilin), Bet v 1, Cup a 1, Art v 1, Ole e 1, Par j 2 > using ImmunoCAP. 2626

Only 40% of mugwort SPT positive were consistent with AR. SPT to grass pollen was 96% consistent with symptoms of AR during the peak season -10% had negative sIgE to major components; 11% of these were profiling/polcalcins + -This would have lead to 90% AIT prescription (SPT and CRD inconsistency 10%) Only 40% of mugwort SPT positive were consistent with AR. - 69% of patients had inconsistency btw SPT and CRD 2727

Impact of IgE-sensitivity to profilins and other cross-reacting molecules on immunotherapy prescription Decision on experimental AIT preparation according to participating doctors - Of 508 patients with clear history of seasonal AR and positive SPT who are eligible for AIT prescription, 170 (33%) would have received AIT with a different composition, and a further 52 (10%) would have received no SIT at all Clinical Implications: Pollen-related AR, applying CRD leads to changes in a large proportion of SIT prescriptions as opposed to relying on clinical history and SPT alone. The hypothesis that CRD-guided prescription improves SIT efficacy deserves to be tested. Stringari G J Allergy Clin Immunol. 2014;134:75 Tripodi J Allergy Clin Immunol. 2012;129(3):834-9 2828

Impact of IgE-sensitivity to profilins and other cross-reacting molecules on immunotherapy prescription Most commercial allergen extracts used in AIT are well standardized for major allergens They contain only minimal or variable amounts of minor allergens Patients sensitized to minor allergens alone most likely will not receive sufficient amounts of allergen to achieve a successful outcome by SIT. Focke M, et al: Heterogeneity of commercial timothy grass pollen extracts. Clin Exp Allergy 2008 Focke M, et al: Molecular composition and biological activity of commercial birch pollen allergen extracts. Eur J Clin Invest 2009

Efficacy of AIT according to sensitivity to major and/or minor pollen allergens Retrospective evaluation of AIT and its impact on sensitization patterns : n=746 Major allergens : Bet v 1 and / or Phl p 1 / Phl p 5. Minor allergens : Bet v 2 / Bet v 4 or Phl p 7 / Phl p 12 Efficacy Major + Minor + Minor - Major - Total None 24 13 41 6 84 Moderate 109 28 26 3 166 Good 123 137 9 269 Very Good 74 147 227 330 325 82 746 ** 73% efficacy observed in patients sensitised to major allergens vs only 16 % in minor allergens sensitised patients Schmid-Grendelmeier P: Recombinant allergens. For routine use or still only science? Hautarzt 2010, 61:946–953.

Efficacy of AIT according to sensitivity to major and/or minor pollen allergens Theme-suggestion Symptoms ( March / April ) Symptoms ( May-July ) Major allergens Bet V1 Cross-reacting Bet V2, Bet V4 Major allergens Phl p 1, 5 Cross reacting Phl p 7, 12 CRD Indication for birch SIT Indication for grass SIT CRD Bet V1: positive Bet V2, 4: Negative High High Phl p1, 5: positive Phl p7, 12: Negative Bet V1: positive Bet V2, 4: positive Phl p1, 5 : positive Phl p7, 12 : positive Bet V1: negative Bet V2, 4: positive Low Low Phl p1, 5 : negative Phl p7, 12 : positive Schmid-Grendelmeier P: Recombinant allergens. For routine use or still only science?

Patterns of HDM sensitization and implications for AIT J Batard et al; Allergy 2015 1300 HDM allergic patients were assessed for 12 purified allergens from Der p or Der f across Europe, Japan and North America

Patterns of HDM sensitization and implications for AIT <10% Patterns of Der p/f sIgE sensitization Der p/f 1-2 >80% - Major allergens Der p 4, 5, 7, 13, 15 21 23 > 20% Der p 10 <10 %- Minor allergen # 6–7% of patients have IgEs to group 1 only #19–22% of patients have IgEs to group 2 only *Mite-specific AIT should rely upon a mixture of D. pteronyssinus and D. farinae extracts with both major allergens

Allergen Components-cross reactivity and their severity Increase risk to cause severe clinical symptoms/ heat stable Protein Family Storage protein Tropomyosins Profilin Procalcins PR-10 LTP Allergen Cross rx Pen a 1 Der p 10 Ani s 3 OAS Bet v 2 Phl p 12 Pru p 4 Hev b 8 Phl P 7 Bet V4 OAS Bet v 1, Ara h 8 Gly m 4, Cor a 1 Pru p 1, Api g 1 Mal d 1, Act d 8 Dau c 1 OAS, severe rx Ara h 9, Cor a 8 Pru p 3, Par j 2 Art v 3 Severe systemic rx Ara h 1, 2, 3 Wheat anaphylaxis, Sastre J CEA 2010, 40, 1442