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哮喘變應(yīng)原免疫治療現(xiàn)狀與思考上海交通大學(xué)醫(yī)學(xué)院蘇州九龍醫(yī)院倪殿濤過敏性疾病作為一個全球性問題WAOWhiteBookonAllergy2011-2012Asteadyincreaseintheprevalenceofallergicdiseasesgloballyhasoccurredwithabout30-40%oftheworldpopulationnowbeingaffectedbyoneormoreallergicconditionsTypesofallergiesAllergen
Any
substance
often
a
protein
that
induces
an
allergy
Commonallergens過敏原種類很多“除了水、葡萄糖和鹽之外都可以成為過敏原”CommoncoldorallergyAsthmaDerivedfromtheGreekrootασθμαινωOriginallydidnotdefineadisease,butwasemployedtodescriberespiratorysymptomsofavarietyofpulmonaryconditionsBythebeginningofthe20thcentury,
asthma
wasseentobeauniqueillnesscharacterizedby'spasmodicafflictionsofthebronchialtubes'.Today,
asthma
isseenasachronicinflammatorydiseasewhichisnotyetfullyunderstoodinitspathophysiologyTherapyisstillonthepathtobecomingoptimal.BergmannKC.Asthma.ChemImmunolAllergy.2014;100:69-80.盲人摸象2014GINA哮喘表型Allergicasthma:usuallyrespondwelltoinhaledcorticosteroid(ICS)treatmentNon-allergicasthma:oftenrespondlesswelltoICS.Late-allergicasthma:someadults,particularlywomen,patientwithasthmaforthefirsttimeinadultlife.Thesepatientstendtobenon-allergic,andoftenrequirehigherdosesofICSorarerelativelyrefractorytocorticosteroidtreatmentAsthmawithfixedairflowlimitation:somepatientswithlong-standingasthmadevelopfixedairflowlimitationthatisthoughttobeduetoairwaywallremodeling.Asthmawithobesity:someobesepatientswithasthmahaveprominentrespiratorysymptomsandlittleeosinophilicairwayinflammation.GINAGuidelinesforAsthma2014Terminologyofallergicphenomena'idiosyncrasy'-'antipathy'-'Hypersensitivity'-'Anaphylaxis'-'allergyA.F.CocaandR.A.Cookeintroducedtheterm'atopy':'hypersensitiveness'occurredspontaneously'atopy'gainedanewsense,sinceIgEisacharacteristic-Clinicallysimilardiseasessuchasasthma,rhinoconjunctivitisoreczemacanbefoundintheabsenceofIgE,andarethencalled'intrinsic'variantsofthesamediseaseChemImmunolAllergy.2014;100:46-52.CoombsandGell’sClassificationofHypersensitivityDoes"intrinsic"asthmaexist?Tentofortypercentofasthmaticsare"intrinsic"Analysisofbronchialmucosalexpressionof"pro-eosinophilic"and"pro-atopic"markers[IL-3,-4,-5,-13,GM-CSF,RANTES,MCP-3,IgEandhighaffinityIgEreceptor(FcepsilonRI)]ThereweremoresimilaritiesthandifferencesinimmunopathologybetweenatopicandnonatopicHumbertM.Does"intrinsic"asthmaexist?RevMalRespir.2000Feb;17(1Pt2):245-54..Allergicvsnonallergicasthma:
whatmakesthedifference?Nonallergic:Greaterage,femalesex,sinusalpolyposis,andFEV1below80%ofthepredictedvalueAllergic:historyofhayfever,seasonalexacerbationofasthma,andasthmadurationAllergy.2002Jul;57(7):607-13.Asthmaphenotypes:nonallergic(intrinsic)asthma.Thedefinition:subjectswithasthmaandwithwhomallergicsensitizationcannotbedemonstratednegativeskinpricktestorinvitrospecific-IgEtesttoapanelofseasonalandperennialallergensNonallergicasthmaoccursin10%to33%ofindividualswithasthmaandhasalateronsetthanallergicasthma,withafemalepredominance.NonallergicasthmaappearstobemoreseverethanallergicasthmainmanycasesandmaybelessresponsivetostandardtherapyPetersSP.Asthmaphenotypes:nonallergic(intrinsic)asthma.JAllergyClinImmunolPract.
2014Nov-Dec;2(6):650-2..Noveldiagnosticapproachesandbiologicaltherapeuticsforintrinsicasthma.ControversieshaveemergedinrelationtothisconceptNotfindingspecificallergensensitizationinanasthmaticpatientneitherexcludesanallergiccomponentnortheessentialrolethatimmunoglobulinEmayplayinasthmaTheatopicstatusisoneamongmanyotherquestionsOmalizumab,theonlymonoclonalanti-immunoglobulinEantibodycommercializedforasthma,shouldbetriedinpatientswithuncontrolledsevereasthmaindependentoftheiratopicstatus
VenneraMdelC1,
PicadoC1.Noveldiagnosticapproachesandbiologicaltherapeuticsforintrinsicasthma.IntJGenMed.
2014
Jul8;7:365-71.哪些哮喘患者需要行AIT?過敏的概念總tIgESentietalAllergy2011;66(6):7981911Noon1thSCIT1950s1thSCITControlStudy;1980s1thDBPCSLIT;2000s1thsublingualTablet2011sInnovatingforpatientbenefit100yeasofantigenspecificimmunotherpyAllergenspecificimmunotherapySelf-amplificationmechanismsofmastcellactivation:
anewlookinallergy.Thecurrentdefinitionofallergy,agroupofIgEmediateddiseasesappearsdifficulttocoverallallergicreactionsSinceevenIgEdependentallergicreactionsarecarriedoutthroughactivationofmastcellsandbasophils,andallallergensmentionedabovecanactivatethesecellswehypothesizethatallergicreactionsaremastcellandbasophilmediatedinflammatoryprocessasitistheactivatedmastcellsandbasophilsthatinitiatethepathologicalprocessoftheimmediateallergicreactionswhereas
IgEonlyservesasoneoftheactivatorsofthesecells.HeS,ZhangH,ZengX,YangP.CurrMolMed.2012Dec;12(10):1329-39.過敏性疾病實驗室診斷的理想程序皮試、斑貼試驗↓(陽性)過敏原、半抗原或小分子物質(zhì)↓嗜堿性粒細(xì)胞/肥大細(xì)胞激發(fā)試驗 ↓(陽性)(陰性基本排除急性過敏)
特異性IgE、IgG檢測
(陰性)
(陽性)
(陽性)
類過敏反應(yīng)IgE依賴性IgG依賴性
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