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

2. 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

3. 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

4. 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

5. 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

6. 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

7. SPT to common inhaled allergens

8. 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

9. 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

10. 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

11. 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

12. 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.

13. Symptom scores before/after SLIT

14. “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

15. 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

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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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)

24. AIT and Grass pollen allergy

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

26. 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

27. 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

28. 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

29. 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

30. 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.

31. 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?

32. Patterns of HDM sensitization and implications for AITJ
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

33. 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, > 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

34. 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