Wheat-dependent, co-factor augmented anaphylaxis; a prospective study of exercise, aspirin and alcohol efficacy as co-factors

Publication date: Available online 7 July 2018

Source: The Journal of Allergy and Clinical Immunology: In Practice

Author(s): Morten J. Christensen, Esben Eller, Charlotte G. Mortz, Knut Brockow, Carsten Bindslev-Jensen

Abstract

Background

Wheat-dependent, exercise-induced anaphylaxis (WDEIA) is severe and potentially life-threatening allergy caused by wheat ingestion and most commonly in combination with exercise.

Objective

To investigate the role and impact of different co-factors (exercise, aspirin and alcohol) in patients with WDEIA.

Methods

We studied 25 adult patients with WDEIA. Diagnostic workup included specific-IgE to omega-5 gliadin and skin prick test (SPT) with wheat flour and gluten. Titrated oral challenge was performed with gluten at rest, combined with treadmill exercise, aspirin, alcohol or exercise+aspirin.

Results

A positive challenge to gluten was found at rest (without co-factors) in 48%(12/25), with exercise in 92%(23/25), aspirin in 84%(21/25), alcohol in 56%(9/19) and with exercise+aspirin in 82%(18/22). With exercise as co-factor the median threshold was 24g (range 4.8g–80g), with aspirin 8g (range 2.4g–80g) and with alcohol 28g (range 0–45g). The combination of two co-factors (exercise and aspirin) resulted in a median threshold of 4.3g (range 1.1g–48g). The threshold for the clinical reaction was lowered by 63%, 83%, 36% and 87% respectively, compared to at rest.

The mean severity grade (scale 0-5) according to Sampson's severity score was at rest 0.8 (range 0-2), combined with exercise 2.1 (range 0-5), with aspirin 1.9 (range 0-5), with alcohol 0.8 (range 0-2) and with the combination of exercise + aspirin 1.5 (range 0-2)

Conclusions

Our results demonstrate that exercise and aspirin augment clinical reactions in WDEIA by lowering threshold and increase the severity of the allergic reaction, whereas alcohol gave ambiguous results. Secondly, a combination of two co-factors (exercise+aspirin) further increase the risk of reactions.