One of the dominant themes of Medicine in the last 50 years has been change. This includes both change created by technical advances and changes in disease that in most cases should be seen as consequences of changes in our lifestyle. Change in the patterns of diseases related to allergic responses to our environment have led to several sequential epidemics of disease.
Most obviously for us the identification of the syndrome of delayed anaphylaxis to red meat and the development of the method of diagnosing the condition was dependent on the development of an IgE antibody assay for alpha-gal (Chung et al New Eng J Med 2008; Wilson and Platts-Mills 2018).
With the development of monoclonal antibodies around 1980, both Tannox and Genentec focused on developing monoclonal antibodies to IgE. The introduction of Omalizumab came 20 years later and is now accepted as an important part of the management of both asthma and chronic urticaria. Equally important it was the key to our accepting the use of biologicals in the treatment of allergic disease. Studies on the use of inhibitors of interleukins have been around for over 20 years. Indeed Dr. Borish published a paper on the use of an IL-4 inhibitor in the treatment of asthma in 1999. Most recently a monoclonal that blocks both IL-4 and IL-13 (dupilumab) is producing clinical results in several different diseases including atopic dermatitis, asthma, sinus disease, and eosinophilic esophagitis. More remarkable still the company involved is considering trials with a monoclonal designed to kill plasma cells in the bone marrow followed by treatment with the monoclonal against IL-4 and IL-13 so that the bone marrow is repopulated without IgE plasma cells. Overall the use of biologicals has already made major changes to our practice, however it is likely that these agents will transform the practice of allergic disease completely over the next 20 years.
In parallel with the changes an allergic disease the immunodeficiency world has expanded very rapidly. This is in part because of the availability of novel treatments but more importantly because it is increasingly easy and affordable to carry out genome sequencing. The result has been that there are now hundreds of syndromes that can be defined by genetics and in many cases the treatment has become both more rational and more effective. We know the clinics run by Dr. Lawrence and Dr. Borish which focused on immunodeficiency to be very busy. During the time that Peter Heymann and I ran the training program in allergy and immunology i.e. from 1986-2016, we observed a truly remarkable increase in food allergy. This was first obvious as an increase in “immediate” often severe allergic reactions to food in childhood. This included milk, egg and tree nuts but was dominated by peanuts. More recently and certainly after 1990 there has been a progressive increase in cases of the completely different eosinophilic esophagitis (EoE). Our current view is that these increases in two forms of food allergy reflect distinct change in lifestyles. This disease for which we now have both adult and pediatric clinics as a collaboration between Emily McGowan and both adult and pediatric GI may well reflect changes in the processing of food over the last 40 years.
It is truly exciting to be part of such a dedicated and talented community of professionals working together to meet head-on the rapid changes facing the world of Medicine.
~Thomas AE Platts-Mills, MD