哮喘變應(yīng)原免疫治療現(xiàn)狀與思考-蘇州九龍醫(yī)院倪殿濤

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