Interview with Prof. Antti Lauerma

Interview with Prof. Antti Lauerma, MD, Congress Chair EAACI 2017

With more than 8,200 visitors from all over the world, this year´s EAACI held in Helsinki was the largest allergic meeting ever held. In the interview, Congress Chair Prof. Antti Lauerma comments on highlights of the meeting and future challenges in allergology.

Which congress topics are of special interest for you?

Lauerma: I really think prevention and quality of life are very important. These topics have been stressed already for the last two years. We would like that allergic patients can lead a good and healthy life despite having this condition or a tendency for allergies. Also, patient education will always play an important role as it can help to prevent errors leading to worse outcomes instead of sustaining benefit.
The amount of people suffering from some kind of allergy is rising constantly and many people believe that preemptive avoidance of an allergen will be good for them even if they are not really allergic to it. This is rather harmful than beneficial.

We have a special program here in Finland ongoing from 2008 to 2018. We have been putting a lot of work into reducing the burden of allergy on society by working together with government, medical societies and patient organisations in order to put common sense into medical practice by inducing tolerance instead of allergy.

Steps taken are very practical. We have e.g. increased the diversity of food intake in young children and managed to get rid of unnecessary diets in kindergartens, schools and workplaces. On the other hand, we have worked on ensuring that patients with serious allergic disease get the best possible treatment. Therapy should go to those patients who really have serious allergic disease, not to those who only think they have an allergy problem.

Which are the most interesting fields of research at the congress?

Lauerma: For me it is very important that with the help of basic science we are getting closer in understanding the interplay between the different factors determining when and how someone will get an allergy. Epidemiologic research does really help to find out possible causes of allergy like certain lifestyles. Investigation of settings of living that influence allergic disposition is a matter of ongoing and ground-breaking research worldwide at the moment. For example, there has been the insight that farm-style or countryside living with lots of allergen contact is beneficial for health as along with urbanisation allergy has been increasing. These findings cannot be directly explained by the progress of urbanisation and we still try to unravel its influence on allergy. The questions of allergic epidemiology are currently being tackled from basic science as well as big data. Research is convincing us that the way to go forward with allergy is not allergen avoidance but tolerance. We have found that someone allergic to peanuts who avoids even the slightest allergen contact will after 6 months have a much stronger reaction to a peanut contact than someone who at least took in a little amount of the allergen. This is why we encourage patients to oral intake of very little amounts of the allergen as it works as natural immunotherapy. Of course, this intake should be started under medical guidance but it has been proven that this is a very good way of prevention. For the same reason, we e.g. have no obligatory instructions to ban dog keeping in homes of people with allergic rhinitis (AR) except in cases of very serious allergic reactions to contact with animals.

What about the importance of the microbiome?

Lauerma: The microbiome revolution has been started about 8 years ago due to new molecular techniques that enabled us to find out more about the bacteria that was not growing in the laboratory. I myself have been researching the microbiome of the skin and it ended up to the finding that 99% of the bacteria found in the skin had been unknown before. The investigations have concluded into an explosion of information. So far, we have very promising data and insight to the gut microbiome in many diseases with substantial impact on gastroenterology. There are also a few results for the skin microbiome up to now, but the therapeutic influence is not yet clear. We know that the microbiome under physiological conditions consists of hundreds and thousands of different microbes. Healthy skin is such that it is difficult for the bacteria to live there. This is why in healthy skin we always see a big diversity of different bacteria; as no bacteria is dominating the area, anyone has to find their own small economic niche. But if after killing a lot of bacteria through cleaning or use of antibiotics living environment is too hygienic, e.g. the microbiome of the skin gets dominated by one species and that causes very big problems. In atopic disease, the skin swab will find one specific bacteria e.g. Staphylococcus Aureus that dominates and wipes out the other bacteria completely.

In a joint research project between Finland and Russia we are currently investigating differences in the appearance of allergy in both parts of Karelia. Very interestingly, we have already seen great differences in the northern part of Karelia right on the border between the two countries, as allergy is a lot more common on the Finnish side than on the Russian. We are speaking of a magnitude around a 30-fold prevalence. Drinking water and environmental dust on both sides of the border were analysed. It was found that water in Finland is much more sterile than in Russia. It also has very few and not diverse bacteria. Don’t get me wrong, of course drinking water has to be healthy, but a too clean environment tends to have very little diversity in the microbiome and there is very strong evidence from multiple studies that this non-diversity in the Finnish environment causes more allergic disease - in short: the more diversity of bacteria the less allergy.

What role do and will biologics play in allergology?

Lauerma: A very significant role: Personally, as a researcher I have been very surprised by the growing success of biologics during the past 15 years. In the beginning, it did not seem to be possible to block just a single interleukin, but now selectivity turns out to be very efficient. Effectiveness of e.g. TNF-inhibitors in treating disease like Crohn’s, psoriasis or rheumatoid arthritis (RA) is amazing and there are yet many, many biologics in the pipeline. Also drugs for atopic dermatitis (AD) are coming. These agents are helping the patients but of course costs also have to be considered. There is an understandable desire for profit in pharmaceutical companies and they cannot give their drugs for free, but in the wake of infliximab’s patent having expired the prices are coming down and it is not really a matter of money any more to get these treatments done. Criteria about which patient is benefitting are needed though. How to allocate resources is a very common problem, not only in allergology and hospitals are facing very big ethical and financing problems. In allergology the most expensive treatments cost about € 20,000 per year but in oncology you can easily face costs up to € 500,000 per year. From a pure medical point of view, we will achieve a better future for our patients using biologics, but it takes time for society and health system to get adjusted. In the end people get these medicines and this will prevent e.g. a lot of permanent joint damage in RA and because of the treatment a diagnosis like RA will no longer be the end of the world. The same is true for allergology and dermatology.

What are the biggest future challenges in the treatment of allergic diseases?

Lauerma: It has been estimated that by 2025 half of the European population will have some kind of allergic or atopic disease. Today we can already look back on success: with the current treatment possibilities, we did not have any children dying from anaphylaxis in Finland for the past 10 years, also serious asthma cases with hospitalisation have disappeared. But diseases thought to be less severe like AD and AR do not only lower quality of life but also work ability. During the season, a patient with AR will suffer from a 20% reduction of his ability to function at work; this is a greater reduction than a patient with coronary disease experiences. In real time data, we have found half or even more students having allergic rhinitis at the time when they are trying to read and learn, just imagine the impact!

We need approaches that have common sense and are applicable for most of the people to treat these seemingly little harm-causing but actually individually very much troublesome common allergic diseases like AR, AD and normal asthma. Keeping these problems under control is possible but it also requires active partaking from the patients. We talk about personalised information for patients by the aid of modern technology like mobile phones, computers or government collaborated patient registries, so there will be a lot more algorithms and instructions coming out. If we get patients to take responsibility, they become the greatest benefactors of their own health.



Posted on 21 June, 201716 March, 2021