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 Eosinophilic esophagitis (EoE) is a chronic immune/antigen mediated esophageal inflammatory disease associated with esophageal dysfunction resulting from severe eosinophil-predominant inflammation Furuta GT et al. N Engl J Med . 2015 October 22; 373(17): 1640–1648.
Up to 70% of pediatric and adult EoE patients have either a history of atopy or even concurrent allergic disease EoE children EoE adults Sensitizations Sensitizations to to food-allergens aeroallergens Ridolo E et al. AsiaPacAllergy 2012; 2:237-241
Ridolo E. et al Ann Allergy Asthma Immunol. 2011 Jan;106(1):73-4. Sanchez Garcia S et al. JACI vol.129, n. 4, 2012. 3 cases of esophageal eosinophilia in 110 patients treated with milk OIT at our outpatient clinic.
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 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 esophagitis: clinical and endoscopic features Ridolo E et al. J Allergy Ther 2014 31 pts
Il ruolo della dieta nell’EoE 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
Dellon ES et al. Am J Gastroenterol 2013; 108:679-692.
Quale dieta? Allergy testing-directed Elemental diet 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
Nutrients in foods commonly eliminated during eosinophilic esophagitis (EoE) elimination diet therapy Groetch et al. J Allergy Clin Immunol Pract 2017;5:312-24
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
Natural salicylates foods Estimated median daily salicylate intakes in the UK population 4.4 mg/day for males and 3.2 mg day females
Prohibited food For 3 weeks, 140 subjects with severe-moderate UAS, followed a pseudoallergen-free diet and kept a clinical diary for UAS4 score and DLQI Magerl M. et al. Effects of a pseudoallergen-free diet on chronic spontaneous urticaria: a prospective trial. Allergy 2010
E il ruolo dell’istamina….???? Maintz et al. Histamine and histamine intolerance. Am J Clin Nutr 2007
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.
CSU due to histamine intolerance appears to be rare and cannot be diagnosed based on the history. Siebenhaar F et al. JEADV 2016;30, 1774-1777.
• 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
7 LOW-NICHEL DIETS • 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 Pizzuttelli S. Reply to: 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 Pizzuttelli S. Update on Systemic Nickel Allergy Syndrome and Diet. Eur Ann Allergy Clin Immunol 2015
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
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.” Van Neerven RJJ et al. Nutrition and allergic diseases. Nutrients 2017, 9, 762.
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)
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