Potential effect of the administration of substance P and allergen therapy on immunoglobulin E-mediated allergic reactions in human subjects
ROY PATTERSON, KATHLEEN E. HARRIS, LESLIE C. GRAMMER, PAUL A. GREENBERGER, ANNE M. DITTO, and MARTHA A. SHAUGHNESSY
CHICAGO, ILLINOIS
Previously we observed and reported that immunoglobulin E-mediated (IgE-medi- ated) allergy in rhesus monkeys was decreased by the administration of substance P (SP) and an allergen. We extended these studies to human subjects, giving SP and I allergen to subjects with reactivity to more than I allergen, using reactivity to a second allergen as a control. SP and an allergen were initially given by aerosol delivery but subsequently were given by injection. The administration of SP and I allergen by aerosol delivery or injection resulted in decreased IgE-mediated reac- tivity to the allergen administered and also to the control allergen. This result occurred in 7 of 8 human subjects. The 2 initial subjects receiving 8 SP and aller- gen injections had a sharp reduction in their symptoms of ragweed hay fever last- ing for 3 years to date. No significant reactions to the injection of SP occurred. Fur- ther controlled human research is necessary on the administration of SP and aller- gen and the mechanisms of action. Unexpected and serendipitous results first observed in rhesus monkeys and reproduced in allergic human subjects provide a new and potential mechanism for control and perhaps obliteration of common IgE-mediated allergies and even more-serious allergic problems. (J Lab Clin Med 1999; 133:189-99)
Abbreviations: D50 : d i lu t ion a t wh i ch 50 mm of e r y t h e m a occurs ; ELISA = enzyme- l i nked immunosorben t assay; IgE = immunog lobu l in E; SP = subs tance P
T he evolut ion of the studies repor ted here began as an attempt to evaluate the effect of tachykinins
on the enhancement of a i rway react iv i ty to an al lergen (Ascaris suum) in rhesus monkeys with IgE-
media ted asthma. The results of exper iments with SP demonstra ted only a transient enhancement of a i rway
reactivity in this primate model of allergic asthma. 1 As these experiments were concluded, a quantitative analy- sis of the cutaneous react ivi ty of the monkeys to the Ascaris ant igen was carr ied out. A surpr is ing and serendipitous discovery was made that the IgE-mediat- ed skin reactivity declined in all monkeys. Over a peri- od of years the administrat ion of antigen alone did not resul t in a decrease in al lergic reactivity. Thus the decl ine in al lergic react iv i ty in combina t ion with SP was a new observation. This decl ine in react ivi ty per- sisted for at least 1 year and was s ta t is t ical ly signifi- cant at P < .001. 2 The obvious explanation was that the aerosolized SP and allergen resulted in a decline in IgE- mediated allergic reactivity.
The goal of the present s tudy was to determine whether the results found in monkeys could be repro- duced in human allergic subjects. This report describes
189
190 Patterson et al
Table I. Graded doses of al lergen by injection ( low-dose formulat ion)
Injection number Dose of allergen (AU)
1 0.5 2 1.0 3 1.5 4 2.0 5 2.5 6 3.0 7 4.0 8 5.0
the evolution of studies from allergic subhuman pri- mates to allergic human primates. Further, the method of administration progressed from aerosol delivery to subcutaneous injection, a far simpler system for human use. In these prel iminary human studies, no adverse
reactions of significance to systemic injections of SP and allergen occurred. Finally, and most important, the
therapy not only appears to affect the allergic reaction
to the allergen injected with SP but also extends to other IgE-mediated allergies. The potential benefits of the
ultimate therapies that evolve are open to speculation
but are likely to include major advances in the therapy of IgE-mediated allergic diseases.
METHODS
SP procedures. SP approved for human use was purchased from Sigma Chemical Co, St Louis, MO. SP was dissolved in sterile water for injection, USP (Abbott Laboratories, North
Chicago, IL), and was filtered through a 0.22 gm Millex fil-
ter (Millipore Products Division, Bedford, MA). Dilutions
were made with buffered 0.9% saline solution (Bayer Corp,
AU/mL) was obtained from Bayer Corp. Standardized short ragweed extract (100,000 AU/mL) was obtained from Greet Laboratories Inc, Lenoir, NC. American elm (1:10 wt/vol) and allergens used for puncture testing were obtained from Allergy Laboratories of Ohio, Columbus, OH.
Study participants. Two of the investigators participated in initial studies to determine and evaluate the concentrations of SP to be used for the aerosol and injection protocols. Sub- sequently volunteers were recruited. Subjects were healthy men or women who had cutaneous reactivity to perennial rye grass or short ragweed or both. These studies were carried out according to the principles of the Declaration of Helsinki with the approval of the Northwestern University Office for the Protection of Research Subjects Institutional Review Board. Informed consent was obtained from all subjects. Three subjects received aerosolized SP and allergen and 6 subjects received SP and allergen by subcutaneous injection.
Cutaneous testing. The initial subject was skin tested by using traditional cutaneous testing methods. 3 Puncture and
J Lab Clin Med February 1999
intradermal skin testing was performed by using methods sug- gested by the FDA 4 to common aeroallergens, dog, cat, feath- ers, and house dust mite for all subsequent subjects. A per- manent record of the skin reactions was obtained by outlin- ing the wheal and area of erythema with ink, placing a piece of transparent tape over the inked outline, lifting the tape, and placing the tape on a sheet of paper.
Subjects who had reactivity to short ragweed, perennial rye grass, or both were selected for the studies. Subject 1 was skin tested before treatment with only 2 dilutions of rye grass allergen, a 10 -4 dilution that gave a sum of erythema ->50 mm and a 10 .5 dilution that was negative. After treatment, sub- ject 1 was skin tested with serial 10-fold dilutions of aller- gen. All other subjects were skin tested with serial 3-fold dilu- tions of allergen with FDA CBER 1Ds0 EAL end point (Ds0) methods, 4 which enabled us to determine the dilution of aller- gen required to produce a sum of 50 mm of erythema. In brief, the Ds0 determinations were performed by injecting 0.05 mL of serial 3-fold dilutions of allergen intradermally into the volar surface of the arm. A dose-response curve was generat- ed by using the sum of erythema results falling within the limits of 0 to 125 mm. The sum of erythema was determined by measuring and recording the longest diameter of erythe- ma. At a point perpendicular to the midpoint on the longest diameter, a second measurement (the orthogonal) was taken. The sum of the longest diameter plus the orthogonal diame- ter gave the sum of erythema. A dose-response curve was gen- erated by using the sum of erythema of each of the four seri- al 3-fold dilutions, and a best-fit regression line was calcu- lated. The Ds0 was determined by using the formula Ds0 = (50 - intercept)/slope.
The D50 determinations were performed at least twice, 3 to 4 weeks apart, before the initiation of the treatment phase to assure the stability of the subject's cutaneous reactivity. The Ds0 determinations were then performed monthly at the completion of the treatment. For subject 1, the Ds0 determinations were extrapolated by using the results from the 10-fold dilutions.
Aerosol exposures. In brief, with methods suggested by Chai et al,5 the aerosolization of SP or allergen was performed with a calibrated Rosenthal-French dosimeter and a DeVilbiss #646 nebulizer. A decline in forced expiratory volume in 1.0 second equal to or greater than 20% was considered positive.
All aerosol exposures were performed at least 1 week apart. The initial aerosol exposure consisted of increasing concen- trations of allergen alone to determine the allergen threshold for the subject. Four subsequent challenges consisted of SP (2 mg given as the first SP aerosol or 4 mg in the subsequent three exposures) and increasing concentrations of allergen until a positive reaction occurred or the maximum dose, 1000 AU/mL, was achieved. The starting dose of allergen used in the initial allergen aerosol was the end point dilution deter- mined during cutaneous testing. In subsequent allergen aerosol exposures, the starting dose was 10 -3 of the reactive allergen dose determined in the initial allergen exposure. The maximum concentration of allergen aerosolized did not exceed 1000 AU/mL. The forced vital capacity and forced expiratory flow at 25% to 75% of forced vital capacity were measured as well as the forced expiratory volume in 1.0 sec- ond during all aerosol exposures.
J Lab Clin Med Volume 133, Number 2 Patterson et al 191
Allergen injections. Challenges consisted of an injection of SP followed by an injection of allergen, and then followed by a second injection of SR The injections were given in dif- ferent sites on the same day as follows. Increasing concen- trations of allergen were preceded by an injection of 0.005 mg of SP and injected according to the schedule shown in Table I. Fifteen minutes after the injection of allergen, a sec- ond injection of SP (0.005 mg) was given; then the patient was observed for 15 more minutes and was discharged.
Assessment of reactions. After each aerosol exposure of allergen or SP the subject was evaluated for symptoms or change in pulmonary functions.
After each injection of SP or allergen the subject was eval- uated for local reactions at the injection site or systemic symptoms for a total of 45 minutes, including 30 minutes for allergen injection.
Assessment of symptoms during pollen seasons. In the 1995 pollen season, symptoms were evaluated by question- ing the subjects regarding the severity of their symptoms dur- ing the grass and ragweed pollen seasons in Chicago. The evaluations during the pollen seasons of 1996 were seriously complicated by the severity of the mold season because of unique climatologic effects, and all test subjects were mold reactive.
ELISA p r o c e d u r e . The ELISA procedure was performed according to the modification of methods described previous- ly. 6,7 In brief, Immunolon micro ELISA plates from Bellco Glass Inc, Vineland, NJ, and a 200 gL per well volume were used for all steps. Plates were washed three times with phos- phate-buffered saline solution-Tween (0.05%)(Sigma Chem- ical Co, St Louis, MO) between all steps. Additions to the plate were perennial rye grass or short ragweed in carbonate buffer (pH 9.6), dilutions of test serum samples, rabbit anti- human IgE (Sigma), alkaline phosphatase-conjugated goat anti-rabbit IgG (Sigma), and finally, p-nitrophenyl phosphate (Sigma 104 phosphate, 1 mg/mL) in 10% diethanolamine buffer, pH 9.8. The reaction was read on an MRX EL1SA reader (Dynex, Chantilly, VA) when a positive control sam- ple reached a predetermined optical density at 405 nm. ELISA end points were read as the last dilution at which the test anti- serum had an optical density reading that was still two times that of the mean of the negative control serum sample.
Total s e r u m IgE. Quantitation of total serum IgE was per- formed by using the 3M Total IgE II FAST (fluorescent aller- gosorbent test) assay (3M Diagnostic Systems Inc, Santa Clara, CA). The lowest detectable concentration in our labo- ratory is 2.4 ng/mL.
Statistical analyses. Statistical analyses were performed by using the nonparametric two-tailed Wilcoxon signed ranks test with SPSS 7.5 for Windows software (SPSS Inc, Chicago, IL).
RESULTS
Response to aerosol delivery of SR The ini t ial expo- sure of SP to an investigator resulted in no respiratory symptoms or change in pu lmonary functions. Al l sub- sequent exposures to all subjects had the same result. Mild, transient facial f lushing occurred after some SP aerosol exposures.
E 60
=< so
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Fig 1. Initial subject treated with aerosolized SP (2 or 4 mg) and aerosolized increasing concentrations of rye grass allergen to a max- imum of 1000 AU/mL. A decline in erythema (A) and wheal size (B) over time in the subject's cutaneous reactivity at a 1:10,000 dilution of rye grass is shown.
Allergen reactivity after aerosolized SP and aerosolized allergen exposure. Subject 1 had cutaneous react iv i ty to grass but no symptoms during the grass pol len sea- son. The exper imental program and results are shown graphica l ly in F ig 1 for the 1:10,000 di lut ion only, because serial 10-fold di lut ions of a l lergen were not used until treatment was completed in this subject. The cutaneous reactivity declined and disappeared, and the aerosol exper iments were extended to subject 2. The
results of the Ds0 analyses of subject 2 are shown in Fig 2.
Subject 2 had a decline in cutaneous reactivity to both rye grass and ragweed (the control) allergen. We expect- ed only a decline in the allergen (grass) used for treat- ment, but an explanat ion for the dual response could have been the adminis t ra t ion of the ragweed al lergen used for skin testing.
A third subject received aeroso l ized SP and grass allergen. The experimental program in this subject was erratic because of recurrent sinusitis (considered unre- lated to the challenges) that interfered with the outcome
192 Palterson et al J Lab Clin Med February 1999
14
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13
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11
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t-a 16
Mean D5o pre treament
~ S P and Allergen Administrations I ~ ~ Cutaneous Testing
Rye Grass
Mean Dso 15 pre treament
14
13
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Fig 2. Subject 2 was treated with aerosolized SP (2 or 4 mg) and increasing concentrations of rye grass to a maximum of 1000 AU/mL. Skin reactivity to rye grass and ragweed are shown. A decline in skin reactivity to both grass and ragweed occurred, Vertical arrows indi- cate the times of skin testing for both rye grass and ragweed.
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Fig 3. Subject 3 was treated with injected SP (0.1 mg per session for 8 weeks) and ragweed (with the schedule shown in Table I). Skin reactivity to ragweed and American elm is shown. A decline in reac- tivity to both ragweed and elm occurred and then returned to pre- treatment levels.
assessment, and this subject is not included in our analysis.
Results of injections of SP and al lergen in human sub- jects: First study. Injections of SP resulted in mild flush- ing at times in 2 subjects. Small wheal and erythema reactions were seen in both subjects but not with all injections in either subject. Subject 3 was reactive to short ragweed and American elm and received injec- tions of SP and ragweed according to the protocol shown in Table I.
The cutaneous reactivity of subject 3 to ragweed and American elm is shown in Fig 3. Cutaneous reactivity to both allergens declined and then returned to pretreat- ment levels. A transient increase in skin reactivity to both allergens was seen in September 1995.
Because of the reproducibility of the skin testing tech- nique, a variation in technique appears unlikely. The increase in skin reactivity was not accompanied by symptoms of ragweed rhinitis. The only explanation thus being considered is a rise in skin reactivity with- out an effect on the end organ (nasal) reactivity. This is also shown by the subsequent rise in skin reactivity that was not accompanied by a parallel increase in symp-
toms. Of particular note was that subject 3 had no symp- toms during the ragweed seasons of 1995 and 1996 and only slight symptoms in 1997, although severe symp- toms had been present for the previous 20 years.
Subject 4 was reactive to both ragweed and rye grass and received injections of SP and rye grass. The results of skin tests for cutaneous reactivity are shown in Fig 4. Cutaneous reactivity to both the injected allergen (grass) and the control allergen (ragweed) declined. Again, the transient rise in reactivity to both allergens occurred in September 1995, as in subject 3. Subject 4 had no symp- toms during the grass or ragweed seasons in 1995 or 1996 and had moderate symptoms in 1997, although this subject had had severe symptoms for more than 30 years before the SP-allergen therapy. Subject 4 also noted a marked decrease in allergic symptoms caused by house dust mite and cat exposure. Thus, allergic symptoms after SP and rye grass injections decreased or removed symp- toms of grass, ragweed, dust mite, and cat allergen.
Results of injections of SP and al lergen in human sub- jects: Second study. Four new volunteers were recruit- ed for the injection regimen shown in Table I. All four had histories of grass and ragweed rhinitis and were
J Lab Clin Med Volume 133, Number 2
positive to those allergens by cutaneous tests. They were also strongly positive to mold allergens by cuta- neous tests. All received injections of SP and rye grass allergen by subcutaneous injection. There were mini- mal local reactions at the site of injection of SP or rye grass allergen in some subjects after some injections, but none of these was considered significant by either subject or physician.
The results of the SP and rye grass injection in sub- jects 5, 6, 7, and 8 are shown in Table II. The percent change in allergen dose required to produce the same degree of sum of erythema (50 ram) is tabulated for both the injected allergen (rye grass) and the control allergen (ragweed). Three subjects (5, 6, and 7) required significantly more grass and ragweed allergen to pro- duce the same degree of erythema. This confirms the previous results in prior subjects that the injection of SP and one allergen reduced responsiveness to both the injected allergen and the control allergen. One subject (number 8 in Table II) did not respond with a lower degree of reactivity.
Symptoms during the ragweed season of responding subjects (5, 6, and 7 in Table II) in 1996 were minimal, requiring only occasional antihistamines. Further, all subjects were mold sensitive, and the mold season in Chicago was extremely severe in 1996. The average weekly mold count during the ragweed season of 1996 was approximately 46 times higher than the same peri- od in 1995. The mold season in Chicago was so severe that our clinical practice saw patients in 1996 (not in this study) who had never experienced symptoms from mold exposure in prior years. This was during the rag- weed season in ragweed-negative subjects. This made the improvement in test subjects in 1996 who were all mold sensitive very difficult to assess.
Cumulat ive exper ience with skin reactivity of all sub-
jects t rea ted with SP a n d al lergen. These resul ts are
shown in Figs 5 and 6. All subjects except subject 8 showed a decline in cutaneous reactivity to both grass (Fig 5) and ragweed (Fig 6) allergen. All of the sub- jects had been treated with SP, but none of the sub- jects had received both allergens. Fig 7 summarizes the results of skin reactivity testing in all human sub- jects (except subject 8) treated with SP and one aller- gen. Although the decline in reactivity in some sub- jects in Figs 6 and 7 was minimal, there was a decline in reactivity in all subjects to the allergen used for treatment and the respective control allergen. The clinical impressions of the investigators are that sub- jects with significant pretreatment symptoms of aller- gic rhinitis, especially subjects 3 and 4 (described above), had a significant decline in the severity of symptoms. Further, this decline in symptoms persist- ed far longer (3 years) than the decline in skin reac-
Patterson et al 193
.o e n
Q
1 6
1 5
1 4
13
12
11
10
9
8 7
5
4
Subject 4 ( ~ Ragweed
. , ~ _ _ Mean D50
Rye Grass
Mean D50 pre treatment
SP and Allerger Administrations
2 ~ . , , , , , •
Fig 4. Subject 4 was treated with injected SP (0.1 mg per session for 8 weeks) and rye grass (with the schedule shown in Table I). A decline in reactivity to both ragweed and grass occurred with a return of reac- tivity to ragweed as in subject 3.
tivity. Table III shows the results of the Wilcoxon signed ranks test analyses of the resulting decreases in IgE-mediated cutaneous reactivity after SP and allergen treatment.
ELISA a n d total serum IgE determinat ions, The ELISA for specific IgE to rye grass and ragweed and the total IgE determinations for selected time points (baseline, point at which lowest Ds0 occurred, and the end of study sample) were carried out. Neither test proved to be useful in analyzing changes that occur with SP and allergen treatment. Changes in either assay were not significant. As is known, the in vitro ELISA is less sensitive than cutaneous test- ing.
Preliminary evaluation of safety data. In a total of 266 exposures delivering a total of 171.94 mg of SP in human subjects and monkeys by any route, only mini- mal transient flushing was observed. There were no changes in vital signs. Occasionally a subject devel- oped a small local reaction at the site of the SP injec- tion that resolved quickly. This was not seen with all injections of SP in any subject.
Subjects minus / • Subject 6 / ~ Subject 7 Subject 8 ~ , Subject S
2
= ~ ' - - ! 6
PRE POST PRE POST
Time with Respect to Substance P Plus Allergen Treatment
Fig 5. For each subject, the mean of the initial Dso and the D50 achieved after treatment with rye grass is shown. Subject 8 is the only subject not demonstrating a decrease in IgE-mediated cutaneous reactivity after SP and rye grass treatment.
Table II. Difference in amount of allergen needed to elicit the same degree of skin reactivity in human sub- jects: Second study
Subject
Percent change AUImL AU/mL in requirement
pre SP+A post SP+A pre vs post required to produce required to produce to produce
The development and study of the rhesus monkey model of primate IgE-mediated allergic reactions extended over many years. 8 Studies of potential bioac- tive mediators of IgE-mediated asthma were a major part of initial studies. 9-11 These were followed by stud- ies of antagonists of bioactive mediators of primate allergic asthma. 12-15 In more than 2 decades of study of rhesus monkeys, with IgE-mediated allergic cuta-
neous reactivity, a major characteristic observed was that the immediate type of cutaneous reactivity persist- ed in the selected population of monkeys for many years. About 20% of monkeys raised in the wild have immediate-type cutaneous reactivity, similar to the inci- dence of allergic human IgE-mediated reactivity. This persistent IgE-mediated reactivity characteristic of the allergic monkey model made it a valuable resource for research of this type of reactivity in primates. Thus it
J Lab Clin Med Volume 133, Number 2 Patterson et al 195
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Fig 6. For each subject, the mean of the initial Dso and the Ds0 achieved after treatment with ragweed. Subject 8 is the only subject not demonstrating a decrease in IgE-mediated cutaneous reactivity after SP and ragweed treatment.
was totally unexpected that the research on SP, con- ducted to study enhanced airway reactivity, 1 was fol- lowed by a decline in IgE-mediated cutaneous reactivi- ty after the administration of SP and an allergen by aerosol delivery. 2
These results suggested the potential for a reduction in IgE-mediated reactivity in human subjects. The experimental protocols in human subjects were con- ducted with great caution to ensure human safety and to fulfill the study criteria submitted.
SP combined with very-low-dose rye grass allergen injections resulted in sharp reductions in immediate skin reactivity to rye grass and short ragweed. In con- trast, conventional allergen immunotherapy does not result in important changes in immediate skin reactivi- ty to the injected allergen. In a 1.5-year study with rag- weed immunotherapy performed by Creticos et al, 16 serum and ragweed IgE antibodies doubled in the first 3 months after injections were begun, then declined, but stabilized at a level greater than baseline.
The aerosolized SP and allergen studies in human subjects were safe and successful, but the process of aerosol administration was tedious and would have been difficult to extend to clinical practice. To improve the potential for human clinical use, the route of admin- istration was changed to subcutaneous injection. The
results of these experiments in 1995 appeared safe and successful and were extended in 1996. The results reported here again demonstrated safety and success in the reduction of IgE-mediated cutaneous reactivity.
However, again in this study of the effect of SP and allergen, two additional unexpected results occurred. First, the IgE-mediated cutaneous reactivity to the unin- jected control allergen decreased, indicating that the administration of SP and one allergen reduces allergic reactivity to another allergen that has not been inject- ed. Second, the 2 subjects treated in 1995, a laboratory assistant and a veterinary trainee working on an advanced degree, were available for close clinical assessment and had a marked decrease in allergic reac- tivity to the injected allergen and the control allergen for 3 years. Symptoms in the 1996 treatment group were also minimal.
The safety of the aerosolized and injected SP, although conducted in limited numbers of human sub- jects and monkeys, provides preliminary information on safety, because no adverse reactions occurred in any rhesus monkey receiving aerosolized SP or in any human subject who received aerosolized or injected SE
Future studies . The results reported here obviously need extension to increase the number of subjects. We must use a graded higher dose of allergen to extend the
J Lab Olin Med 196 Patfferson et al February 1999
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Fig 7. A composite graph showing the mean of the Ds0 analyses to rye grass and ragweed performed before SP and allergen treatment, as compared with the lowest Ds0 achieved after treatment for all subjects except subject 8.
Table IlL Wilcoxon signed ranks test analyses (two-tailed) of the resulting decreases in IgE-mediated cuta- neous reactivity after SP and allergen treatment
Allergen Including all subjects* Excluding subject 8*
Rye grass Z = -2 .197, P = .028 Z = -2 .201, P = .028 Ragweed Z = -2 .197, P = .028 Z = -2 .201, P = .028 All a l lergens Z = -3 .237, P = .001 Z = -3 .233, P = .001
*Mean D50 result before SP and allergen t reatment was compared with the lowest Ds0 ach ieved after t reatment for each subject. The results of subject 1 "s Ds0 determinations were performed by using 10-fold dilutions.
duration of decline in cutaneous reactivity. We must have measurement of the quantitative reduction of symptoms. A placebo group (for SP) will be essential.
Because the initial discovery and the two additional
findings of a decrease in control allergen reactivity and the long duration of symptom reduction were serendip- itous, we were not following the usual scientific approach of working out a hypothesis and testing the
J Lab Clin Med Volume 133, Number 2
f a b l e IV. S o m e possib le m e c h a n i s m s of SP a n d
a l l e rgen in r e d u c t i o n of I g E - m e d i a t e d a l le rg ic r eac t i on
1. Decrease in IgE antibodies 41,42 2. Depletion of mast cells 43 3. Depletion of IgE binding sites on mast cells or
basopNIs 44 4. Decrease in reactivity to bioactive mediators such as
histamine 45 5. Alteration of response to bradykinin 46 6. Alteration of interleukins 4, 5, 12, 2, and 2-R 26,40,47-49 7. Alteration of interferon-y34, 36 8. Change in glycosulation status of Fc£ 50,51 9. Combinations of the above 10. A totally new mechanism of alteration of IgE antibody-
mediated responses
hypothesis by various research approaches. Instead, we were determining whether the rhesus monkey results could be extended to human subjects, and, as reported here, they were.
We have considered poss ible mechanisms of action of SP-al lergen therapy. Representa t ive reviews of SP research for the last 17 years show mul t ip le immuno- logic effects. 17-21 The repor ted results demonst ra te a great range of diverse effects of SP and other tachykinins. Some studies demonstrate mediator re lease 22 and chemotac t ic activity23, 24 and the enhancement of cytokine production.25, 26 Other studies repor t a l tered mast cel l reactivity. 27:30 The modula t ion of mucosa l
immuni ty has been reported, as has direct act ivi ty on IgA and IgM production. 31
Reports of the effects of SP and a specific antigen are far fewer than the reports of the effects of SP alone. Human lymphocytes have receptors for SP on their sur- face. 32,33 In cultures of human cells, it has been report- ed that SP increases mitogen-induced IgA and IgM pro- duct ion 34 and that it decreases IgE product ion. 2I
Mur ine lymphocytes also have SP receptors on their surface. 35
In mur ine models evaluat ing the effect of SP and a specific antigen, several potentially relevant results sug- gesting a switch from TH2 to TH1 phenotype have been reported. Mur ine lymphocytes receiv ing subopt imal doses of schis tosomiasis antigen and SP substant ial ly increased interferon-y production36; they also produced s ignif icant ly h igher amounts of specif ic IgG2a. 37 SP has been reported to suppress benzy l -pen ic i l loy l - spe - cific IgE in cultured murine spleen cells from previous- ly sensi t ized animals; 3s this suppress ion appeared to involve interferon-y. 39 Finally, SP has been reported to s ignif icant ly increase in ter leukin-12 product ion by
Patterson et al 197
murine macrophages exposed to Salmonella. 4o In a review of the wide spectrum of activities on the
immune system, we found no clear correlation with the results we report here. We do not know the mechanism of act ion of SP-al lergen therapy. Much l ike the years of s tudy of a l lergen immunotherapy after the demon- strat ion of efficacy, the mechanisms wil l have to be es tabl ished in the future. We suggest poss ible mecha- nisms of the action of SP-allergen in Table IV.
REFERENCES
1. Patterson R, Harris KE. Substance P and IgE-mediated allergy. I. Transient increase in airway responsiveness to allergen in primates. Allergy Proc 1993;14:49-51.
2. Patterson R, Harris KE. Substance P and IgE-mediated allergy. II. Reduction of rhesus IgE antibody following aerosol exposure to substance P and allergen. Allergy Proc 1993;14:53-9.
3. Booth BH. Diagnosis of immediate hypersensitivity. In: Patterson R, Grammer LC, Greenberger PA, editors. Aller- gic diseases: diagnosis and management. 5th ed. Philadel- phia: Lippincott-Raven; 1997. p. 177-9.
4. Turkeltanb PC, Rastogi SC. Quantitative intradermal pro- cedure for evaluation of subject sensitivity to standardized allergenic extracts and for assignment of bioequivalent allergy units to reference preparations using the IDs0 EAL method (intradermal dilution for 50 mm sum of erythema determines bioequivalent allergy units). In: Methods of the Allergenics Products Testing Laboratory, LIB, DAPP, CBER, FDA, Food and Drug Administration, docket no. 94N-0012, October 1993, p. 91-114.
5. Chai H, Farr RS, Froehlich LA, Mathison DA, McLean JA, Rosenthal RR, et al. Standardization of bronchial inhalation challenge procedures. J Allergy Clin Immunol 1975;56:323-7.
6. Voller A, Bidwell DE, Bartlett A. Enzyme immunoassays in diagnostic medicine: theory and practice. Bull WHO 1976;53:55-65.
7. Sepulveda R, Longbottom JL, Pepys J. Enzyme-linked immunosorbent assays (ELISA) for IgG and IgE antibod- ies to protein and polysaccharide antigens of Aspergillus fumigatus. Clin Allergy 1979;9:359-71.
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