RAMSES (NCT03126227) and ARTEMIS (NCT03201003) were phase 3, randomized, placebo-controlled trials that evaluated Peanut (Arachis hypogaea) Allergen Powder-dnfp, an FDA-approved oral immunotherapy biologic for the treatment of peanut allergy. Entry required a strong clinical history and positive skin prick test (SPT) and/or peanut-specific IgE (psIgE). The primary endpoint in ARTEMIS was efficacy using double-blind, placebo-controlled food challenge (DBPCFC) assessed at baseline and after ∼9 months of treatment; RAMSES was for safety assessments without an entry DBPCFC.

We hypothesize that treatment with omalizumab prior to starting oral immunotherapy (OIT) will reduce symptoms, allowing acceleration of the build-up phase and achievement of maintenance dosing more quickly. Peanut-allergic patients aged 12 years and older were enrolled in this study. Omalizumab was given for 4 months prior to initiation of OIT, followed by a modified rush day(s), a build-up period, and a daily home maintenance phase with a final dose of 4000 mg of peanut protein. Omalizumab was continued for one month after reaching maintenance dosing. 6 patients had evaluable safety data. The median peanut-specific IgE in this group was 68.7 kU/L. The median total IgE was 486.5 kU/L. 6/6 patients experienced symptoms on the rush desensitization days with 20/21 symptoms graded as mild, primarily respiratory in nature, comparable to previously published safety data for rush desensitization without omalizumab. The median peanut starting dose after rush desensitization with omalizumab was 300 mg (range 100-400), higher than that seen without omalizumab pretreatment. On dose escalation days, 9.5% of doses (6 of 63) resulted in symptoms in the omalizumab group, in contrast to 43.3% of doses (123 of 284) resulting in symptoms in previous studies [RR 0.22 (95%CI 0.10-0.48), p<0.0001]. These results, although limited by small sample sizes, suggest that omalizumab therapy has the potential to reduce side effects during dose escalation and allow a higher starting dose of peanut. This may enhance safety and allow patients to reach maintenance dosing sooner than in previous peanut OIT trials.

BACKGROUND:In Westernized countries, over 1% of the population is allergic to peanuts or tree nuts, which carries a risk of severe allergic reactions. Several studies support the efficacy of peanut oral immunotherapy (OIT) for reducing the clinical sensitivity of affected individuals; however, the mechanisms of this effect are still being characterized. One mechanism that may contribute is the suppression of effector cells, such as basophils. Basophil anergy has been characterized in vitro as a pathway-specific hyporesponsiveness; however, this has not been demonstrated to occur in vivo.OBJECTIVE:To evaluate the hypothesis that basophil anergy occurs in vivo due to chronic allergen exposure in the setting of a clinical oral immunotherapy trial.METHODS:Samples of peripheral blood were obtained from subjects during a placebo-controlled clinical trial of peanut OIT. Basophil reactivity to in vitro stimulation with peanut allergen and controls was assessed by the upregulation of activation markers, CD63 and CD203c, measured by flow cytometry.RESULTS:The upregulation of CD63 following stimulation of the IgE receptor, either specifically with peanut allergen or non-specifically with anti-IgE antibody, was strongly suppressed by active OIT. However, OIT did not significantly suppress this response in basophils stimulated by the distinct fMLP receptor pathway. In the subset of subjects with egg sensitization, active peanut OIT also suppressed CD63 upregulation in response to stimulation with egg allergen. Allergen OIT also suppressed the upregulation of CD203c including in response to stimulation with IL-3 alone.CONCLUSION:Peanut OIT induces a hyporesponsive state in basophils that is consistent with pathway-specific anergy previously described in vitro. This suggests the hypothesis that effector cell anergy could contribute to clinical desensitization.

RationaleWe recently compared sublingual (SLIT) to oral immunotherapy (OIT) following a short SLIT escalation for treatment of cow's milk (CM)-allergy and found that while SLIT was safer than OIT, it was less efficacious. This analysis sought to determine if a more prolonged period on SLIT could improve safety of subsequent OIT.Methods30 children with IgE-mediated-CM-allergy were randomized to either SLIT (goal 7mg daily, N=10) or 4 weekly SLIT escalations to a dose of 3.7mg followed by OIT (goal 1000 or 2000mg daily, N=20). After 60 weeks of maintenance, SLIT subjects who reacted to less than 4gm CM-protein on food challenge crossed-over to OIT. Dose escalation started at less than ¼ the tolerated food challenge dose and escalated to 2000mg daily for one year. The rates of adverse events across dosing regimens were compared using negative binomial analysis with generalized estimating equations.Results8 SLIT subjects crossed over to OIT. Symptoms occurred with 24.4% of 2251 doses (oral 23.1%, skin 0.84%, GI 0.89%, lower respiratory 0.27% and upper respiratory 0.13%). One subject withdrew due to persistent GI symptoms. Antihistamines and inhaled beta-agonists were given for 1.3% and 0.04% of doses. Although the overall rates of reactions with OIT following brief versus prolonged SLIT were similar (p=0.976), lower and upper respiratory reactions were significantly less common (p=0.02 and p=0.006, respectively) and antihistamines and inhaled beta-agonists used less frequently (p=0.002 and p=0.001, respectively) in the prolonged SLIT group.ConclusionProlonged SLIT before OIT dosing appeared to improve safety, but did not eliminate all symptoms. RationaleWe recently compared sublingual (SLIT) to oral immunotherapy (OIT) following a short SLIT escalation for treatment of cow's milk (CM)-allergy and found that while SLIT was safer than OIT, it was less efficacious. This analysis sought to determine if a more prolonged period on SLIT could improve safety of subsequent OIT. We recently compared sublingual (SLIT) to oral immunotherapy (OIT) following a short SLIT escalation for treatment of cow's milk (CM)-allergy and found that while SLIT was safer than OIT, it was less efficacious. This analysis sought to determine if a more prolonged period on SLIT could improve safety of subsequent OIT. Methods30 children with IgE-mediated-CM-allergy were randomized to either SLIT (goal 7mg daily, N=10) or 4 weekly SLIT escalations to a dose of 3.7mg followed by OIT (goal 1000 or 2000mg daily, N=20). After 60 weeks of maintenance, SLIT subjects who reacted to less than 4gm CM-protein on food challenge crossed-over to OIT. Dose escalation started at less than ¼ the tolerated food challenge dose and escalated to 2000mg daily for one year. The rates of adverse events across dosing regimens were compared using negative binomial analysis with generalized estimating equations. 30 children with IgE-mediated-CM-allergy were randomized to either SLIT (goal 7mg daily, N=10) or 4 weekly SLIT escalations to a dose of 3.7mg followed by OIT (goal 1000 or 2000mg daily, N=20). After 60 weeks of maintenance, SLIT subjects who reacted to less than 4gm CM-protein on food challenge crossed-over to OIT. Dose escalation started at less than ¼ the tolerated food challenge dose and escalated to 2000mg daily for one year. The rates of adverse events across dosing regimens were compared using negative binomial analysis with generalized estimating equations. Results8 SLIT subjects crossed over to OIT. Symptoms occurred with 24.4% of 2251 doses (oral 23.1%, skin 0.84%, GI 0.89%, lower respiratory 0.27% and upper respiratory 0.13%). One subject withdrew due to persistent GI symptoms. Antihistamines and inhaled beta-agonists were given for 1.3% and 0.04% of doses. Although the overall rates of reactions with OIT following brief versus prolonged SLIT were similar (p=0.976), lower and upper respiratory reactions were significantly less common (p=0.02 and p=0.006, respectively) and antihistamines and inhaled beta-agonists used less frequently (p=0.002 and p=0.001, respectively) in the prolonged SLIT group. 8 SLIT subjects crossed over to OIT. Symptoms occurred with 24.4% of 2251 doses (oral 23.1%, skin 0.84%, GI 0.89%, lower respiratory 0.27% and upper respiratory 0.13%). One subject withdrew due to persistent GI symptoms. Antihistamines and inhaled beta-agonists were given for 1.3% and 0.04% of doses. Although the overall rates of reactions with OIT following brief versus prolonged SLIT were similar (p=0.976), lower and upper respiratory reactions were significantly less common (p=0.02 and p=0.006, respectively) and antihistamines and inhaled beta-agonists used less frequently (p=0.002 and p=0.001, respectively) in the prolonged SLIT group. ConclusionProlonged SLIT before OIT dosing appeared to improve safety, but did not eliminate all symptoms. Prolonged SLIT before OIT dosing appeared to improve safety, but did not eliminate all symptoms.

Background: Oral immunotherapy (OIT) and sublingual immunotherapy (SLIT) are potential therapies for food allergy, but the optimal method of administration, mechanism of action, and duration of response remain unknown.Objective: We sought to explore the safety and efficacy of OIT and SLIT for the treatment of cow's milk (CM) allergy.Methods: We randomized children with CM allergy to SLIT alone or SLIT followed by OIT. After screening double-blind, placebo-controlled food challenges and initial SLIT escalation, subjects either continued SLIT escalation to 7 mg daily or began OIT to either 1000 mg (the OITB group) or 2000 mg (the OITA group) of milk protein. They were challenged with 8 g of milk protein after 12 and 60 weeks of maintenance. If they passed the 60-week challenge, therapy was withdrawn, with challenges repeated 1 and 6 weeks later. Mechanistic correlates included end point titration skin prick testing and measurement of CM-specific IgE and IgG(4) levels, basophil histamine release, constitutive CD63 expression, CD203c expression, and intracellular spleen tyrosine kinase levels.Results: Thirty subjects with CM allergy aged 6 to 17 years were enrolled. After therapy, 1 of 10 subjects in the SLIT group, 6 of 10 subjects in the SLIT/OITB group, and 8 of 10 subjects in the OITA group passed the 8-g challenge (P = .002, SLIT vs OIT). After avoidance, 6 of 15 subjects (3 of 6 subjects in the OITB group and 3 of 8 subjects in the OITA group) regained reactivity, 2 after only 1 week. Although the overall reaction rate was similar, systemic reactions were more common during OIT than during SLIT. By the end of therapy, titrated CM skin prick test results and CD63 and CD203c expression decreased and CM-specific IgG(4) levels increased in all groups, whereas CM-specific IgE and spontaneous histamine release values decreased in only the OIT group.Conclusion: OIT was more efficacious for desensitization to CM than SLITalone but was accompanied by more systemic side effects. Clinical desensitization was lost in some cases within 1 week off therapy. (J Allergy Clin Immunol 2012;129:448-55.)

RATIONALE: Peanut OIT induces clinical desensitization while on treatment. We hypothesized that peanut-specific immunoglobulin levels would show a greater change in those peanut allergic subjects ingesting a higher maintenance peanut dose of OIT. METHODS: Peripheral blood specimens were collected from peanut-allergic subjects participating in two peanut OIT protocols. The first was an open label protocol (OL) with a maintenance dose of 300 mg of peanut protein; the second was a double-blind, placebo-controlled trial (PC) with a maintenance dose of 4000 mg peanut protein. Peanut-specific IgE and IgG4 were measured in serum with the ImmunoCAP method. RESULTS: Seven subjects were included from the OL peanut OIT study, and 14 treatment subjects from the PC trial. At 12 months, OL subjects had a greater decrease in peanut-specific IgE when compared to PC subjects (p=0.017). This trend was not seen at 18 and 24 months. Interestingly PC subjects had a greater increase in peanut-specific IgG4 at 12, 18, and 24 months compared to the OL group (p=0.001, 0.004, and 0.003 respectively.) There was no difference in rate of change for peanut-specific IgE/IgG4 between groups at any time point. CONCLUSIONS: After 24 months of OIT, the increase in IgG4, but not the decrease in IgE, appears to be a dose-dependent effect. Further work is needed to determine the mechanism of this immunologic change and whether it has a role in desensitization or tolerance.

RATIONALE: We report an interim analysis in an ongoing study designed to understand the safety, efficacy and potential mechanisms behind the development of desensitization and tolerance in peanut allergic children receiving peanut SLIT. METHODS: Thirteen peanut allergic subjects (1 to 11 years-old) were randomly assigned to receive either peanut SLIT or placebo SLIT. Doses ranged from an initial daily dose of 0.25 mcg peanut (0.015 mcg Ara h2) with bi-weekly up-dosing to 100 mcg peanut (6 mcg Ara h2) at 4 months. Peanut-specific IgE, IgG and IgG4, and titrated skin prick test (SPT) wheal diameters were measured at baseline and 4 months into build-up. Symptom diaries were completed daily by families. RESULTS: Seven of the 13 subjects (median age 4 years 10 months) received peanut SLIT. At 4 months there was no significant change from baseline values for the treatment group regarding peanut-specific IgE (p=0.13), IgG (p=0.40), IgG4 (p=0.66), or SPT wheal diameter (p>0.99). Compared to the placebo cohort there was no significant difference in peanut-specific IgE (p=0.35), IgG (p=0.35), IgG4 (p=0.46), or SPT wheal diameter (p=0.90) at 4 months. All reported side-effects were minor in nature with sneezing, skin itching, lip swelling, mild urticaria and non-specific abdominal pain reported most often. There were no significant differences in subjects reporting any side-effect in the treatment vs. placebo cohorts (p>0.99). CONCLUSIONS: Peanut SLIT appears to be safe in peanut allergic children. Significant immunologic changes were not detected 4 months into build-up dosing.

RATIONALE: Peanut OIT appears to induce clinical desensitization. We hypothesized that allergen-induced basophil activation would be suppressed in patients receiving peanut OIT. METHODS: Peripheral blood specimens were collected longitudinally from peanut-allergic patients participating in a double-blind, placebo-controlled trial of peanut OIT. Unfractionated cells were stimulated with a five-log range of peanut extract (10 μg/ml-1 ng/ml) as well as controls. Basophils were identified by flow cytometry (lineage-, HLA-DR-, CD123+) and activation status defined by CD63 expression. RESULTS: Seventeen patients on either peanut or placebo OIT were assessed for basophil activation. There was a statistically significant decrease of allergen-induced basophil activation at 9-12 months versus baseline in the active peanut treatment group (n = 11, 3.67% vs. 36.7% CD63+ at 0.1 μg/ml, p = 0.011) that was not seen in the placebo group (n = 6, 30.2% vs. 45%, p = 0.91). The same trend was observed for the response to anti-IgE stimulation at 9-12 months versus baseline (p = 0.08 active; p = 0.87 placebo). The degree of basophil suppression was dependent on OIT dose and reached significance at the highest (1.8 gm) dose compared to placebo (5.26% vs. 36.7% CD63+ at 0.1 μg/ml, p = 0.01). CONCLUSIONS: Basophil reactivity can be assessed in clinical trial subjects by flow cytometry. Peanut OIT suppresses allergen-induced basophil activation. Further work is needed to determine the mechanism of this suppression and whether it has a role in clinical desensitization.

Epidemiological and experimental studies suggest that the intake of natural/nutrient products is inversely related to cancer risk, and dietary antioxidants can reduce the risk of certain cancers. Ganoderma lucidum is an Asian medicinal mushroom that has been used for the treatment of various diseases including cancer. We have previously demonstrated that G. lucidum suppresses growth, angiogenesis and invasiveness of highly metastatic breast cancer cells. The present study was undertaken to evaluate the effect of G. lucidum on oxidative stress-induced metastatic behavior of poorly-invasive MCF-7 breast cancer cells. Here, we show that G. lucidum inhibits oxidative stress-induced migration of MCF-7 cells by the down-regulation of MAPK signaling. G. lucidum suppressed oxidative stress stimulated phosphorylation of ERK1/2, which resulted in the down-regulation of expression of c-Fos, followed by the inhibition of transcription factor AP-1. The biological effect of G. lucidum on cell migration was mediated by the suppression of secretion of interleukin-8 (IL-8) from MCF-7 cells. In summary, our results suggest that G. lucidum inhibit oxidative stress-induced invasive behavior of breast cancer cells by modulating of MAPK signaling and could be potentially considered as an antioxidant in adjuvant cancer therapy.