NOVEL APPROACHES IN THE PREVENTION,
DIAGNOSIS, AND THERAPY OF RAGWEED-
INDUCED RESPIRATORY ALLERGIC DISEASES
Prof. Carmen Panaitescu Bunu, MD PhD
Timisoara, 26 April 2016
University of Medicine and Pharmacy Victor
Babes Timisoara
Topics
• Immunological mechanisms of allergy - rationale for treatment and
prevention of allergic diseases
• New trends in allergic asthma treatment
• New trends in allergen-specific immunotherapy (SIT)
• Timisoara experience and INSPIRED project
Allergy - disease of the 21st century
• Hay fever
– Allergic rhinitis (10-30%)
– Allergic conjunctivitis
Allergy – multifaceted disease
• Skin allergy
– Atopic dermatitis
– Urticaria (20%)
• Food allergy
(250 000 000 people)
• Bronchial asthma (235 000 000
patients, 250 000 deaths/year)
• Anaphylaxis
WHO-World Allergy White Book 2011-2012
WAO estimates that allergy prevalence in the whole
population by country ranges between 10 - 40%
3
Valenta R, Nature Reviews Immunology, 2002
Development of the allergic immune response
4
IgE – “key player” in allergic inflammation
Galli SJ, Nat Med, 20135
Topics
• Immunological mechanisms of allergy - rationale for treatment and
prevention of allergic diseases
• New trends in allergic asthma treatment
• New trends in allergen-specific immunotherapy (SIT)
• Timisoara experience and INSPIRED project
Potential points of therapeutic intervention along the
allergy pathway
Hawrylowicz, Nat Rev Immun 2005
Block initiation of
immune response Block Th2
activation
Block effector
molecules of
allergy
7
Casale, JACI 2008
CCR
Anti-IL5
IL-4
IL-13
IL-9
Anti-IL9
Anti-IL4Anti-
IL4Rαααα
Anti-IL13
Anti-IgE
Omalizumab
New trends in allergic asthma treatment: immunomodulation
2005
2015
1. Milgrom B, et al. N Eng J Med 1999;1341(26), 1966–73
SCIT
1903
Topics
• Immunological mechanisms of allergy - rationale for treatment and
prevention of allergic diseases
• New trends in allergic asthma treatment
• New trends in allergen-specific immunotherapy (SIT)
• Timisoara experience and INSPIRED project
SIT mechanisms
Cezmi A Akdis, Nature Medicine, 201210
Immunomodulation induced during SIT
Norman, J Allergy Clin Immunol 2004
1. Mc+Ba
2. Treg
3. IgE
4. IgG4
5. Prick test
6. Tissue Eo
11
A century of SIT - Critical points
Valenta, JIM 2012
1903
Oral administration of
pollen extract for SIT
(Black)
1927
Adsorption of
allergens onto
aluminium salts for SIT
(Sledge)
1938
Subcutaneous injection of
grass-pollen extract in
allergic patients reduces
allergic symptoms (Noon)
1911
SIT induces an allergen-
specific serum factor that
inhibits allergic reactions
(Cooke)
1935
Controlled SIT
study (Frankland)
1954
Coupling PEG renders
allergens nonallergenic and
tolerogenic (Lee & Sehon)
1977
SLIT for tolerance
induction
(Scadding&Brostoff)
1986
Synthetic allergen-derived
T-cell epitope-containing
peptides for SIT (Norman)
1996 2002
First SIT with recombinant
hypoallergenic allergen
derivatives (Niederberger)
2004
SIT with purified allergen
conjugated to immunostimulatory
DNA sequences (Creticos)
2006
SIT prevents progression
towards severe allergy
(rhinitis–asthma) (Moller)
Pollen-specific anti-sera
neutralize pollen-induced
allergic reactions (Dunbar)
Ideal immunotherapy
13
New approaches to SIT
14
From allergen genes to allergy vaccines
Valenta & Niederberger, Annu Rev Immun 201015
cDNA sequence
mRNA
Allergen sources
reverse transcription
Recombinant allergen sequence
Three-dimensional allergen structure
Production of recombinant allergens
Nandy, Allergo J Int 2015
Biotechnology used by Biomay GmBH Austria for production of
grass pollen and house dust mite recombinant allergens for SIT
⇓
New step: ragweed SIT
16
Dillemas regarding SIT with recombinant allergens
17
SIT side effects
Focke, Clin Exp Allergy 201018
Strategies for decreasing SIT adverse effects
Valenta & Niederberger, Annu Rev Immun 201019
Topics
• Immunological mechanisms of allergy - rationale for treatment and
prevention of allergic diseases
• New trends in allergic asthma treatment
• New trends in allergen-specific immunotherapy (SIT)
• Timisoara experience and INSPIRED project
Aim of study
1. Determine the relevant indoor and outdoor allergens in the Western region of
Romania
2. Determine the impact of sensitization to ragweed pollen in patients from the
Western region of Romania
3. Evaluate and compare the immune response of patients allergic to different
ragweed species, in order to assess:
• Patient exposure to different ragweed species (A. artemisiifolia and A.
trifida)
• Sensitivity and specificity of allergen microarray ImmunoCAP ISAC for
specific serum IgE
• Cross- or co-sensitization between ragweed species
21
Material and methods
22
Ragweed pollen in the Western part of Romania
2000 - 2009
Concentration
Linear (concentration)
23
Results
Polysensitized and monosensitized patients 2008 - 2014
24
Results
25
Results
Monosensitized patients 2008 - 2014
26
Recombinant Amb a 1 for production of a
hypoallergenic vaccine
• Study: Cross-sectional observational study performed with Biomay GmBH
Austria/MUW and DIATER Laboratorios, Spain
• Duration: July – November 2014
• Subjects with allergic rhinoconjunctivitis ± allergic bronchial asthma (according
to ARIA and GINA criteria):
– Group I: 97 patients (89 allergic + 8 non-allergic controls)
– Group II: 25 patients (allergic to ragweed)
• What:
1. SPT with commercially available aeroallergen extracts (“gold standard”)
2. Microarray for component-resolved diagnosis: specific serum IgE using
ImmunoCAP ISAC → MedALL microchip, which includes 176 different proteins
(FP7) (97 samples)
3. Immunoblotting and ELISA inhibition to A. artemisiifolia and A. trifida pollen
extracts to assess cross- or co-sensitization between the two spp (25 samples)
27
Ragweed study
• 97 subjects included:
84 patients allergic to ragweed pollen
13 controls5 allergic to other aeroallergens
8 nonallergic
Mild intermittent allergic
rhinitis
Mod-severe intermittent
allergic rhinitis
Mild persistent allergic
rhinitis
Mod-severe persistent
allergic rhinitis
28
Microarray for component-resolved diagnosis
ImmunoCAP ISAC
microarray chip
Valenta, Viena 2013
MedALL microchip
including 176 different
proteins
29
Patient distribution
Monosensitized to Ambrosia
Polysensitized
Polysensitized
to pollens
Polysensitized
to various
aeroallergens
30
ImmunoCAP ISAC Amb a 1
Method:
Standard microarray, at the Pathophysiology and Allergy Department
Medical University Vienna,
Prof. Rudolf Valenta
Microarray chip with 176 allergens / sample
n = 84
Class 0
Class 1
Class 3
Class 4
31
ImmunoCAP ISAC vs Prick test (ragweed) correlation
32
Results – Immunoblotting Amb a vs Amb t
Courtesy of Mr. Fernando Pineda de la Losa
Amb a 1
Amb a 11?
Amb a 6-10
33
Results – ELISA inhibition
Courtesy of Mr. Fernando Pineda de la Losa
ELISA inhibition Amb a vs. Amb t
(serum pool from clinically characterized ragweed allergic subjects)
34
Conclusions
• In the Western part of Romania, the most important clinical relevant
allergens are
– Outdoor - ragweed pollen
– Indoor - house dust mites
• The vast majority of patients allergic to ragweed pollen are sensitized
specifically to A. artemisiifolia
• There is no significant cross- or co-sensitization between A. artemisiifolia and
A. trifida
• Ragweed may contain other clinically relevant allergens besides Amb a1 that
should be identified and introduced in the component-resolved diagnosis kit,
as well as in a future immunotherapeutic product
– A better characterization of T and B cell epitopes from ragweed pollen is
required for a better therapeutic approach
35
Conclusions
• SIT represents the only disease-modifying therapy in allergy
– Efficient immune modulator
– Should be recommended if pharmacological therapy is not efficient or tolerated
• Critical issues for immunomodulators:
– Many options for similar cases
– Optimal treatment goals are not yet accomplished
• Decreased symptoms, exacerbations and improved QOL
• Prevent/alter disease course
• Cost effective
• Favorable risk/benefit ratio Too powerful
Broad-spectrum
Too weak
Very specific
36
The usefulness of component-based diagnosis
Valenta, Nat Rev Imm 2002
Multi-allergen test system
(allergen microarray)
37
Thank you !
Prof. Rudolf Valenta,
MUW
Dr. Eva Wollman,
MUW
Dr. Frank Stolz,
Biomay Viena
Ing. Cristinel Gheorghiu,
Bioclinica Laboratory
Mr. Fernando Pineda de la
Losa
DIATER Spain