Aeroallergens and EoE with Dr. Amal Assa’ad

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Host Ryan Piansky and co-host Mary Jo Strobel, talk with guest Dr. Amal Assa’ad about aeroallergens, food allergies, and eosinophilic esophagitis.

Dr. Assa’ad is a pediatric allergist. She is a Professor at the University of Cincinnati in the Department of Pediatrics, as well as the Director of Clinical Services and Associate Director of the Division of Allergy and Immunology at Cincinnati Children's Hospital Medical Center. She is an accomplished, award-winning researcher who has published more than 100 peer-reviewed manuscripts and book chapters.

In this episode, Mary Jo and Ryan invite Dr. Assa’ad to share her academic path and the research she has done on eosinophilic esophagitis (EoE) as well as current research directions. Dr. Assa’ad discusses how environmental allergens and EoE connected and why treatments for allergies are ineffective at preventing EoE. She also discusses a study on the demographic differences in the diagnosis of EoE and shares her optimism for biological treatments in the pipeline for eosinophilic disorders.

Disclaimer: The information provided in this podcast is designed to support, not replace the relationship that exists between listeners and their healthcare providers. Opinions, information, and recommendations shared in this podcast are not a substitute for medical advice. Decisions related to medical care should be made with your healthcare provider. Opinions and views of guests and co-hosts are their own.

This podcast was recorded prior to the FDA approval of Dupixent for indicated treatment of eosinophilic esophagitis for people aged 12 and older.

Key Takeaways:

[1:11] Mary Jo introduces today’s guest, Dr. Amal Assa’ad, Professor at the University of Cincinnati’s Department of Pediatrics, Director of Clinical Services, and Associate Director of the Division of Allergy and Immunology at Cincinnati Children’s Hospital Medical Center.

[1:45] Dr. Assa’ad is an accomplished award-winning researcher. Dr. Assa’ad has published over 100 peer-reviewed manuscripts, book chapters, and research publications. She holds several committee appointments and is an engaging speaker with a gift for teaching difficult concepts in an easy-to-understand way.

[2:29] Dr. Assa’ad is not college-educated! In Egypt, she went directly from high school to medical school. She is the first medical doctor in her family. She wanted to relieve patient suffering and study medical disorders. She started medical school at age 16 and stayed for seven years. At the age of 23, she was a physician.

[3:40] After receiving her MB BCh medical degree, Dr. Assa’ad entered a Master’s program for a degree in testing for food allergies. In the United States, Dr. Assa’ad did a visiting fellowship in San Antonio, Texas, and an internship and residency in pediatrics in Michigan and Dayton, Ohio.

[4:38] From there, she joined Cincinnati Children’s Hospital where she started her work in food allergy and other allergic disorders. She developed an interest in eosinophilic disorders. Dr. Assa’ad was always thrilled to be making science. With other doctors, she worked on several of the initial clinical trials for hypereosinophilic syndrome patients.

[5:51] From these trials, Dr. Assa’ad learned how patients present differently; at different ages, different organ systems affected, and with different quality of life.

[6:07] Dr. Assa’ad started working with eosinophilic esophagitis and eosinophilic gastroenteritis and contributed to the descriptions of these disorders and the study of the pathogenesis, presentations, and epidemiology. She continues to be very interested in the overlap of these disorders with food allergy and environmental allergy.

[6:55] Is EoE always triggered by food? Patients usually say if they take certain foods, they have symptoms that are associated with EoE. The symptoms of EoE are also very difficult to pin down. With infants, the symptom is feeding difficulties. In toddlers, it is vomiting. At school age, stomach aches. In adults, dysphagia, or difficulty swallowing.

[8:52] Quite often, EoE is not diagnosed until a major event happens, like a food impaction, like something getting stuck in the esophagus at dinner. Is it that the food instantly made the EoE worse, or is it the texture issue and the difficulty in the motility of the esophagus that cause the impaction?

[10:09] Are foods the only thing that can increase your EoE symptoms? What about environmental allergens that can contribute? Dr. Assa’ad cites a study in mice where allergens were put into the esophagus or the nose. The observation was that inhaled allergens may cause symptoms to worsen.

[11:00] Patients have been observed with symptoms that cycle with the seasons. Certain seasons were associated with either diagnosing EoE or flare-ups of EoE. There are common proteins between pollen and foods, so the question is: Are these kinds of proteins, whether in foods or inhalants, causing a flare-up of symptoms?

[11:57] When you have a flare-up of symptoms, you assume that you have a worsening of the pathology in the esophagus, so you have more eosinophils. Of course, you don’t get an endoscopy every season, but you could assume the esophagus isn’t working as it should.

[12:25] Dr. Assa’ad thinks that EoE is multifactorial. Different patients have different triggers. In the 1990s, when EoE was being described, researchers did skin tests for environmental and indoor allergens. In Dr. Assa’ad’s published research, some EoE patients had no or few allergies, and others had many reactions to allergens.

[15:38] Dr. Assa’ad believes that patients with large numbers of allergies are patients who are likely to develop eosinophilic esophagitis because they tend to be allergic. She believes that the lining of the esophagus is primed and prone to respond to these food and environmental allergens.

[16:14] How can you determine which foods are problematic for your EoE? Dr. Assa’ad describes the difference between sensitivity and allergy. Many studies were looking for connections between food sensitivities and EoE. Researchers used to try drastic dietary elimination, but now they limit the eliminations to a few foods.

[18:29] In a new study, not yet published, removing a few foods can significantly reduce the EoE symptoms. Some patients know that if they eat a certain food they are going to have symptoms, so they don’t eat it. But don’t restrict your diet to extremes. Maintain a good quality of life.

[20:50] What about seasonal EoE flare-ups? Is that only related to airborne allergens? There are no definitive population studies on this question. It is also very hard to filter out airborne allergens. But what other changes in the environment may cause EoE flare-ups during these cycles? They may be pollution, toxins, dust, and particulates.

[23:15] Dr. Assa’ad was surprised in her research by the number of positive tests she found in the larger part of the patients, who were highly sensitized to a large number of things. These patients were being treated for their symptoms and still got diagnosed with eosinophilic disorder. They were not being treated for the immunologic mechanism.

[24:16] Dr. Assa’ad was excited about a study where they looked at mepolizumab in eosinophilic disorders. The study showed it did decrease the eosinophils in the biopsies but it didn’t meet the primary goal endpoint of ameliorating symptoms, which is something that has plagued a lot of the eosinophilic disorders studies.

[25:39] These study patients came having already had treatments for allergies but they still developed the disorder. Mepolizumab went on to be developed for eosinophilic asthma and eventually for hypereosinophilic syndrome as well, but not for eosinophilic esophagitis or gastroenteritis. Dr. Assa’ad is hopeful it will be developed for EoE.

[26:41] Dr. Assa’ad recommends patients with EoE symptoms that are caused by environmental allergens to treat the allergic symptoms. It’s important for patients to manage their quality of life.

[28:28] It has been noted that epidemiologically, eosinophilic esophagitis and the disorders are more common on the east and west coasts but less common in the middle of the country. Is it the stresses and rapid pace of life on the coasts?

[29:38] Dr. Assa’ad has seen improvement with puffed and swallowed fluticasone. They have published papers on that.

[30:25] The availability of endoscopies and biopsies in the United States is far greater than in other countries, even European countries. The diagnosis of EoE in some countries relies on counting eosinophils in blood samples instead of biopsies. Flare-ups and eosinophil counts do not necessarily correlate. Other countries go by symptoms.

[32:21] Environmental allergens are very different in different countries so the influence of environmental allergens on EoE from country to country cannot be easily compared.

[33:13] What research is next for Dr. Assa’ad? Food allergies and working with colleagues at other institutions on a grant following a cohort of situationally diverse African-Americans and Caucasians with food allergies. They are looking into the diagnosis of eosinophilic esophagitis and how being diagnosed has differed by race.

[34:26] Through this cohort, they have found that EoE is infrequently diagnosed in African-American or Latinx populations that have symptoms that are very consistent with EoE.

[34:45] Dr. Assa’ad is also working on looking at the genetics of food allergies with regard to races and what makes a difference. She is also working on establishing a biobank for food allergy biomarkers for researchers around the country.

[36:04] Another project Dr. Assa’ad is working on is immunotherapy for food allergies. Patients with EoE have previously been excluded from studies with immunotherapy because it might provoke the disorder.

[37:30] Dr. Assa’ad focuses on where the patient is coming from and the patient’s wants and needs. She is working on clinical trials with biologics and is optimistic about the results with acute food allergies and eosinophilic disorders.

[38:07] Mary Jo thanks Dr. Assa’ad for taking the time to talk with us.

[38:16] Dr. Assa’ad shares the optimism that the whole scientific community is making strides. A lot is coming down the pike and things are going to get better from the diagnostic and therapeutic points of view and improving the patients’ quality of life and possibly helping other countries.

[39:19] Ryan invites listeners to look at apfed.org for additional resources to help with the day-to-day management of EoE. Ryan also encourages you to connect with the APFED online community and listen to past podcast episodes.

[39:59] Dr. Assa’ad thanks Ryan and Mary Jo for having her on the podcast and thanks APFED and other patient organizations.

Mentioned in This Episode:

American Partnership for Eosinophilic Disorders (APFED)

APFED on YouTube, Twitter, Facebook, Pinterest, Instagram

Amal Assa’ad, M.D.

University of Cincinnati

Cincinnati Children’s Hospital Medical Center

Food Allergy Research and Education (FARE)

NIH

apfed.org/eoe

APFED EOS Connections Online Community

APFED Podcast Episode Featuring Dr. Gupta

This episode is brought to you thanks to the support of our Education Partners Abbott, Bristol Myers Squibb, GlaxoSmithKline, Mead Johnson Nutrition, Sanofi, and Regeneron.

Tweetables:

“I was always very thrilled to be in a room where we are making science. We are making observations on these eosinophilic disorders and specifically, eosinophilic esophagitis and hypereosinophilic syndrome.” — Dr. Amal Assa’ad

“I would [consider], for each particular person: What is it that makes their symptoms flare up?” — Dr. Amal Assa’ad

“There were first case reports, and then there were retrospective population studies that found that certain seasons were more associated with either diagnosing EoE or flare-ups of EoE.” — Dr. Amal Assa’ad

“What the patient wants and what the patient needs should be our focus.” — Dr. Amal Assa’ad

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