Diete in allergologia: ancora attuali? Prof.ssa Erminia Ridolo - - PowerPoint PPT Presentation

Diete in allergologia: ancora attuali?

Prof.ssa Erminia Ridolo Allergologia ed Immunologia clinica Università di Parma

AGENDA

• Esofagite Eosinofila Primitiva
• Orticaria Cronica Spontanea
• SNAS
• Dermatite Atopica
• Prevenzione delle allergie

Eziopatogenesi

Furuta GT et al. N Engl J Med . 2015 October 22; 373(17): 1640–1648.

Eosinophilic esophagitis (EoE) is a chronic immune/antigen mediated esophageal inflammatory disease associated with esophageal dysfunction resulting from severe eosinophil-predominant inflammation

Up to 70% of pediatric and adult EoE patients have either a history of atopy

• r even concurrent allergic disease

EoE children

Sensitizations to food-allergens

EoE adults

Sensitizations to aeroallergens

Ridolo E et al. AsiaPacAllergy 2012; 2:237-241

Ridolo E. et al Ann Allergy Asthma Immunol. 2011 Jan;106(1):73-4.

3 cases of esophageal eosinophilia in 110 patients treated with milk OIT at our outpatient clinic.

Sanchez Garcia S et al. JACI

vol.129, n. 4, 2012.

• B. D. van Rhijn et al. Allergy 2013

Pollen and food sensitizations may cause or mantain esophageal inflammation in EoE patients. Aeroallergen sensitization, mostly against components of grass or tree pollen, or house dust mite, was observed in 74% of the patients. Birch pollen (rBet v 1) sensitization with cross-reactivity to food allergen components was observed in 30 pts (39%). A role for pathogenesis-related proteins in poly-sensitized allergic patients with eosinophilic esophagitis: clinical and endoscopic features Ridolo E et al. J Allergy Ther 2014 A role for pathogenesis-related proteins in poly-sensitized allergic patients with eosinophilic esophagitis: clinical and endoscopic features Ridolo E et al. J Allergy Ther 2014

31 pts

Lucendo a et sl. Guidelines on eosinophilic esophagitis: evidence-based statements and recommendations for diagnosis and management in children and adultsUnited European Gastroenterology Journal 2017, Vol. 5(3) 335–358

Il ruolo della dieta nell’EoE

Dellon ES et al. Am J Gastroenterol 2013; 108:679-692.

Quale dieta?

Elemental diet Allergy testing-directed elimination diet SFED

Arias A et al. Efficacy of Dietary Interventions for Inducing Histologic Remission in Patients With Eosinophilic Esophagitis: A Systematic Review and Meta-analysis. Gastroenterology 2014;146:1639–1648

Groetch et al. J Allergy Clin Immunol Pract 2017;5:312-24

Nutrients in foods commonly eliminated during eosinophilic esophagitis (EoE) elimination diet therapy

Dieta e orticaria cronica spontanea

10 to 20% of the population will experience an episode of urticaria at some point in their lifetime and 0,1% will develop chronic spontaneous urticaria.

CSU Diagnosis

All subsequent diagnostic steps will depend very much on patient history and on the nature of the urticaria subtype.

Type I allergy is a rare cause of CSU in patients who present with daily or almost daily symptoms, but may be considered in CSU patients with intermittent symptoms.

Pseudoallergic reactions are defined as clinical reactions whose symptoms resemble allergic reactions without identifiable immunologic sensitization.

“ …in a subset of patients with chronic urticaria a diet low in pseudoallergens has been proven to be beneficial in several studies, with response rates observed in more than 55% of patients. DBPC challenge tests have shown that artificial food additives are not only to blame, with the majority of reactions being traced back to naturally occuring pseudoallergens in food. ”

Zuberbier T. The Role of Allergens and Pseudoallergens in Urticaria. Journal of Investigative Dermatology Symposium Proceedings, 2001

Estimated median daily salicylate intakes in the UK population 4.4 mg/day for males and 3.2 mg day females Natural salicylates foods

Magerl M. et al. Effects of a pseudoallergen-free diet on chronic spontaneous urticaria: a prospective trial. Allergy 2010

For 3 weeks, 140 subjects with severe-moderate UAS, followed a pseudoallergen-free diet and kept a clinical diary for UAS4 score and DLQI

Prohibited food

Maintz et al. Histamine and histamine intolerance. Am J Clin Nutr 2007

E il ruolo dell’istamina….????

Wagner N et al. JEADV 2017,31,650-655.

Low-histamine diet is a therapeutically useful, simple and cost-free tool to decrease symptoms and increase quality of life in CsU patients with gastrointestinal involvement. Further research is needed to understand the role of diamine oxidase.

Wagner N et al. JEADV 2017,31,650-655.

Siebenhaar F et al. JEADV 2016;30, 1774-1777.

CSU due to histamine intolerance appears to be rare and cannot be diagnosed based on the history.

• A)number of pts with a histamine-positive history is shown in the

yellow column and the number with a histamine-negative history in the orange column.

• The light green bars; % of pts who had a positive response to diet,

Pink bars: % of pts with a weal response to oral histamine challenge.

• (b) n° pts with a positive response to diet is shown in the light green

column and the number with a negative response in the darker green column. The yellow and pink bars show the percentage of patients within each group who had a histamine-positive history and a weal response to oral histamine challenge respectively.

• (c) n° pts with a positive weal response to oral histamine

provocation is shown in the pink column and the number with a negative weal response in the purple column. The yellow and pink bars show the percentage of patients within each group who had a histamine-positive history and positive response to diet respectively.

Il ruolo del Nichel Solfato

Systemic nickel allergy syndrome (SNAS): Cutaneous and extra- cutaneous symptoms correlated to the ingestion of foods and beverages containing nickel.

Symptoms include:

• respiratory symptoms (occupational rhinitis and asthma);
• urticaria, angioedema;
• gastrointestinal symptoms (recurrent aphtosis, abdominal bloating and

pain, diarrhoea and/or constipation, nausea and or vomiting, with endoscopic findings of chronic gastroduodenitis)

• aspecific systemic clinical manifestations (headache, chronic fatigue, post-

prandial dyspnea, cystitis and/or vulvovaginitis, acne and iron deficiency anaemia).

Ricciardi L. Systemic nickel allergy syndrome: Epidemiological data from fpur italian allergy units. J Neurogastroenterol Motil. 2017 Jan 30;23(1):101-108.

Irritable Bowel Syndrome and Nickel Allergy: What is the role of the low nickel Diet?

Rizzi A et al. J Neurogastroenterol Motil 2017;23:101-108

Pizzuttelli S. Reply to: update on Systemic Nickel Allergy Syndrome and Diet. Eur Ann Allergy Clin Immunol 2015

• Only cocoa, chocolate, peas and canned foods are

always forbidden

• Six out of 7 diets forbid hazelnuts and peanuts
• Five out of 7 diets proscribe beans, lentils, shellfish,

tea, spinach

• Tomatoes, fish, vegetables are allowed in some

diets, not allowed in others

• Although having low-nickel content, beer, red wine,

herrings, mackerel, tuna, raw tomatoes, onions, carrots, apples, citrus fruits and other juices are forbidden in some diets

7 LOW-NICHEL DIETS

Pizzuttelli S. Update on Systemic Nickel Allergy Syndrome and Diet. Eur Ann Allergy Clin Immunol 2015

DOUBTS AND PERPLEXITIES

• Complete elimination of nickel form the diet is impossible (IS

UBIQUITOUS)

• The beneficial effect of a low-nickel diet is not

guaranteed

• Opinions vary about the nickel content wich would determine the

threshold of a low-nickel diet

• There is no unanimity about allowed and forbidden

foods

• Opinions vary about steel pans and kitchen tools, which are not

universally prohibited

• Using tap water is prohibited in some diets, prohibited under

some conditions or allowed in others

• It is not clear how long a low-nickel diet should last

Cutis 2016, Vol 97, 227-232

• 43 articles
• Trials varied in type, duration, and the AD patient populations studied.
• Some level I evidence to support specific exclusion diets in preselected

patients but insufficient evidence for strict elimination diets (diets that are typically limited to six to eight foods).

• Strict elimination diets and caloric restriction remain discouraging.
• It is important to note that any dietary intervention requires medical

supervision and dietary counseling.

• Risks of elimination diets in children: even limited, such as avoidance of

cows’ milk, present a risk of calorie and nutrient malnutrition.

• Elimination diets may weaken oral allergen tolerance and lead to more

robust allergic reactions.

Lim NR et al. Pediatr Dermatol. 2017 Sep;34(5):516-527

Van Neerven RJJ et al. Nutrition and allergic diseases. Nutrients 2017, 9, 762.

Preventive role of diet in allergic diseases?!?

“Dietary components present in a normal diet may contribute to prevention of allergies (asthma, rhinitis, dermatitis, atopy and food allergies), promote the development of allergies (food processing, food allergy), and more specialized foods can be used for the management or even the treatment of food allergy.”

Burbank AJ et al. Environmental determinants of allergy and asthma in early life.J Allergy Clin Immunol 2017;140:1-12.

Lifestyle factors can contribute to or diminish microbial diversity. Many aspects of modernity promote dysbiosis. (Renz et al., J Allergy Clin Immunol 2017;140:24-40)

The first thousand days – intestinal microbiology of early life: establishing a symbiosis

Wopereis H. et al. Pediatric Allergy and Immunology Volume 25, Issue 5, pages 428-438, 5 JUN 2014

• Pioneer species (facultative anaerobic

bacteria) Staphylococcus, Streptococcus, Enterococcus and Enterobacter. After 1-2 weeks: obbligate anaerobes (Bifidobacterium, Bacteroides, Clostridium, Eubacterium)

• After introduction of first solid foods (4-6

months

• f

age): decreased level

• f

Bifidobacteria and gradual diversification towards adul type species (Bacteroides spp and Clostridium IV and XIV)

• Healtly adults have a stable microbiota

Immunomodulatory effects of the microbiota in the gut have the potential to decrease allergic inflammatory responses.

• The

intestinal mucosa is an immune- privileged site, which under normal conditions can tolerate exposure to a huge antigen load without resulting in an inflammatory response.

• The intestinal microbiota can affect both the

innate and adaptive immune pathways.

• Induces

TH1 cell differentiation, which is required to establish a balance between TH1 and TH2 immune responses, which corrects the TH2 skewing that is thought to occur at birth.

• Expansion of Treg cell subsets in the gut is

critically involved in establishing immune tolerance. Treg cells and immunomodulatory cytokines, such as IL-10 and TGF-b, are involved in decreasing or preventing effector T-cell responses that mediate autoimmune or allergic disease.

Mc Loughin RM et a. J Allergy Clin Immunol 2011, 127; 1097-1107.

Microarray analysis reveals marked intestinal microbiota aberrancy in infants having eczema compared to healthy children in at-risk for atopic disease.

Nylund et al. BMC Microbiol. 2013 Jan 23;13:12. doi: 10.1186/1471-2180-13-12.

• Composition of the microbiota did

not differ between study groups at age

• f

6 months, but was significantly different at 18 months.

• Healthy children harboured 3
• fold

greater amount

• f

members

• f

Bacteroidetes (p=0.01).

• Children

suffering from eczema had increased Clostridium clusters IV and XIVa, which are typically abundant

in adults.

Effects of probiotics for the treatment of atopic dermatitis: a meta-analysis of randomized controlled trials

Kim et al. Ann Allergy Asthma Immunol 13(2014);9217e226

• The dose of probiotic preparation used in the

trials ranged from 0.3 billion to 20 billion colony- forming units. This might contribute to the heterogeneity among the studies.

• Applying

the same dose criteria to various products that consist of different strains might be inappropriate: to find the optimal dose of probiotic preparation, a direct head-to-head comparison study is required.

Despite the conflicting data

• btained from clinical trials,

vitamin D deficiency may influence the inflammatory response in the airways.

Hall SC et al. Clinical Therapeutics/Volume 39, Number 5, 2017

• Vit

D3 levels are significantly reduced in subjects with CU.

• Vit D supplementation

as “add-on” therapy shows a greater resolution of CU.

Rasool R et al. WAO J (2015) 8:15.

Miles EA & Calder PC. Nutrients 2017, 9, 784.

Proposed relationship between increased linoleic acid exposure and increased allergic disease. Risk of persistent wheeze or asthma in children according to maternal use of fish oil or placebo during pregnancy.

• A protective

effect on asthma/wheezing symptoms, but not

• n

allergic rhinitis, eczema, or atopy.

• During

pregnancy might have some protective effect

• n

asthma/wheeze symptoms in the offspring only during their first

year of life.

Castro-Rodriguez & Garcia-Marcos. Front. Pediatr. 5:72.

Tanaka T & Takahashi R. Nutrients, 2013, 5, 2128-2143.

Flavonoid intake and risk of chronic diseases

Knekt P et al. Am J Clin Nutr 2002;76:560–8.

CONCLUSIONI

• A tutt’oggi chiare evidenze scientifiche confermano il ruolo delle

diete di eliminazione in caso di esofagite eosinofila primitiva.

• Minor certezze, invece, per Orticaria Cronica Spontanea e

Dermatite atopica.

• Promettenti la dieta mediterranea e diete con supplementazione

di flavonoidi, probiotici e vitamina D per la prevenzione e il trattamento delle patologie allergiche.

• Dieta di eliminazione di nichel solfato: ???

Grazie per l’attenzione

erminia.ridolo@unipr.it