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Food Patch Testing for Irritable Bowel Syndrome

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#1 DermDoc

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Posted 06 April 2013 - 04:29 PM

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Hello all,

 

I am a dermatologist in suburban Philadelphia and thought you would be interested in research my group reported in the March 2013 Journal of the American Academy of Dermatology, "Food Patch Testing for Irritable Bowel Syndrome".  We found that by performing skin patch testing  (a simple, painless procedure we often perform in evaluating patients with a sometimes difficult skin rash called eczema) to many different common foods and food additives on patients with IBS or IBS-like symptoms, we were able to identify foods to which many of the patients reacted, and when they avoided eating these foods, their IBS symptoms significantly improved or disappeared.  We feel this is a significant advance in the understanding of IBS and have proposed that some people with "IBS" really have "allergic contact enteritis"; in other words, these same foods are causing a similar reaction in the intestine as they do on the skin, with the resulting inflammation affecting intestinal motility, causing the IBS symptoms.  You can google our article to learn more. 

 

I am happy to answer any questions about our research.



#2 Kathleen M.

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Posted 06 April 2013 - 06:19 PM

Is this the same or different from the prick testing I've had done for airborne allergens?  I don't really have much eczema problems, mostly allergies and asthma.

 

One time they did the food panel in addition to the pollens and dust panel since I have had IBS symptoms.  While I react all over the place on the pollens and dust the food panel had no reactions at all.  Well one very small reaction to Cantelope which is probably a cross reaction from ragweed.  It kind of validated that I was reacting to pollens and dust and not just the pricking.


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#3 DermDoc

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Posted 06 April 2013 - 06:48 PM

No, this is not the same as prick and scratch testing.  That type of testing is for "Type 1" allergies, such as asthma, hayfever, hives, etc.  Most efforts prior to our study for IBS have looked at this type of testing, including measuring serum IgE levels.  These tests have been found not to be very useful at all for IBS, as concluded by a large consensus report from the National Institute for Allergy and Infectious Diseases.  Essentially , these efforts involving IgE and prick and scratch tests were like "barking up the wrong tree", looking for the wrong type of allergy.

 

Our testing is for "type 4" reactions, which is like poison ivy.  It involves leaving strips of tape comprised of rows of small wells filled with different food allergens on the skin of the back for 48 hours, then performing the readings when the patches are removed and again a day or 2 later.  It is likely that the same type of allergic reaction we are observing in the skin is occurring in the intestine, causing inflammation and affecting the gut's motility.  It used to be thought that the intestine was "normal" in IBS, but in recent years inflammation has been observed.  The cause of inflammation until now, however, has not been known.



#4 Jeffrey Roberts

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Posted 07 April 2013 - 08:41 AM

Thank you for making us aware of your research.

Will you be presenting your research at Digestive Disease Week in Orlando in May?

#5 DermDoc

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Posted 07 April 2013 - 04:19 PM

Hello Jeffrey.  

 

You are welcome.  I am a dermatologist and wasn't aware of this conference until you mentioned it here.  I just looked at the program and it looks like the schedule is already in place.  I would be happy to speak there if the organizers would like and if scheduling of the conference permits.

 

More information is available online about the testing we are now doing for IBS but I don't know if the conditions of use of this forum allow posting it here.  I'd be happy to provide the link if you'd like.

 

Michael Stierstorfer, M.D.



#6 Jeffrey Roberts

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Posted 07 April 2013 - 05:03 PM

You can certainly contact the DDW organizers. Our organization will be in attendance.

It would be good to get some feedback from Gastroenterologists who do IBS research.

You might like to contact Dr. Y Ringel at UNC Chapel Hill and see if there is any interest in further validating the study, http://www.med.unc.e...ehuda-ringel-md

Feel free to mention our organization or my name.

#7 DermDoc

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Posted 07 April 2013 - 07:11 PM

I will look into presenting at the DDW next year.  The deadline for abstract submission for this year was Feb. 15.  I know from experience with our big dermatology meetings, speakers/schedules are planned many months in advance.  I will be presenting our work at Temple University Hospital Gastroenterology Grand Rounds in June.  Much work remains to validate the utility of food patch testing for IBS and we have started that work locally.  I appreciate the information about Dr. Ringel.  



#8 Jeffrey Roberts

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Posted 07 April 2013 - 07:43 PM

DDW is quite an enormous conference. It would have been good to at least had a poster presented.

Dr. W Chey in Michigan would also be another good contact.

http://www2.med.umic...vidual_id=23309

Congrats on your efforts. The IBS community appreciates it!

#9 Jeffrey Roberts

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Posted 08 April 2013 - 10:26 AM

It seems Dr. Chey has already seen and commented on the study in Gastroenterology and Endoscopy News (APRIL 2013 | VOLUME: 64:4).

 

“The concept is really interesting and novel, but there are many problems with the study design,” said William D. Chey, MD, professor of medicine and director of the GI Physiology Laboratory, University of Michigan, Ann Arbor.

 

Larger studies with double-blind design (neither patients or testers were blinded in this study), inclusion of patients with only active IBS, more balanced gender distribution, testing of more foods and food additives, the use of validated assessment tools and more precise quantification of response to dietary avoidance are needed. Only two of the 30 patients who completed the exclusion diet were male, and only 60% of the cohort had physician-diagnosed IBS.

 

Moreover, only 13% of patients who completed exclusion diets reported great improvement. Most patients classified their improvements as moderate or mild (34.7% and 13%, respectively).

 

“That could be simply placebo effect,” Dr. Chey noted.

 

“I think there is certainly something to this concept—I believe strongly that food hypersensitivity is very prevalent—but this paper, unfortunately, doesn’t do very much to help us to answer the question,” said Dr. Chey.



#10 DermDoc

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Posted 08 April 2013 - 07:42 PM

Thank you for finding Dr. Chey's commentary.  We are pleased he expressed interest in our work.  Our study was a proof-of-concept study.  The concerns Dr. Chey raises mirror those we listed as limitations of the study in our report and need to be addressed for validation of the concept. 
 
The following may address some of the concerns:
 
We had patients avoid the foods to which they had positive patch tests for one week only as we felt it would be difficult to ask patients to avoid them for much longer, especially if there was no improvement in one week.  We were confident that one week would be long enough to determine whether there would be improvement based on prior observations we had made.  We shared the concern about placebo effect.  Of the 14 patients who benefited during the study, we had the opportunity three months or longer after the study to ask 11 of them how they were doing.  10 of those 11 maintained their improvement while continuing the dietary avoidance for three or more months.  The one who did not sustain benefit was a woman who reported slight improvement in the study (with sodium benzoate avoidance) but reported sodium benzoate wasn't part of her routine diet.  We feel continued improvement for the other 10 makes placebo unlikely, although this was not reported as it was not part of the original study protocol.  One of the most dramatic results was a woman who had a positive patch test to limonene, which is in citrus.  When asked if she ate citrus regularly, she reported drinking tea with lemon every night.  She stopped the lemon and improved greatly, and it was sustained at the three month follow-up.  Another reported similar success after avoiding dodecyl gallate, a preservative, which she could never have figured out without the testing. 
 
As for blinding study patients, if anyone has a good idea how to do that, we would greatly appreciate letting us know!  I think it would be fairly impossible to blind people to be sure they are avoiding a specific food for several weeks, unless they were placed under 24 hour supervision. 
 
We don't know why most of the subjects were female, certainly far more than the expected 2 to 1 female to male preponderance of IBS.  
 
As for including patients who had GI symptoms suggestive of IBS but not enough to fit the diagnostic criteria, or who did not have physician-diagnosed IBS, we feel (and felt) such testing could benefit them as well and thus included them in this proof-of-concept study.  A more formal validation study for IBS would require more restrictive entry criteria.
 
As for needing more foods and food allergens, we agree.  For the study, we chose food allergens that were most readily available and within budget of our self-funded study.  The type of foods we used are all known to be cause type 4 (poison ivy-like) allergic skin reactions.  We hypothesize the same type of reaction is occurring in the intestine, as the immune system has just as much access to the intestine as to the skin (maybe more since the intestine, unlike the skin, has no stratum corneum to protect it).  We have since been working with university-based food scientists and compounding pharmacists to develop many more of these types of foods and food additives into a patch test-ready form, and now have nearly 120 ready for patch testing.  I can give you more information if you contact me privately--I'm concerned that more info in this forum would not be in compliance with the terms of use--and more information that allows us to be confident our findings are significant, even before the validation studies are done. 


#11 Kathleen M.

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Posted 09 April 2013 - 01:33 PM

If you follow this proticol do I get a mention in the acknowlegements? biggrin.png

 

Compliance will be an issue, and you could have people have to have a smart phone and ask them to message a photo of each meal and snack.  They may still sneak some of the eliminated food, but it gives some accountability and a way to at least make some effort to check what they are eating.

 

If you provide all food with observation for several weeks that gets really expensive really fast.  Worked on a cabbage feeding study where they were observed for breakfast and dinner, were given a boxed lunch and we also had to pay them for each week in addition to getting all their food.

 

Off the top of my head I would likely consider maybe doing a cross-over study. Look at the Low Fodmap diet and based on those foods to eliminate develop one (or maybe a series of diets depending on the size of the study, smaller I might make one, but for a bigger study you can make them more matched up to what kinds of things you have them eliminate based on the test) standarized elimination diet that will remove foods that may make IBS worse (usually foods with fermentable carbohydrates).  So  if on average you have people with the real testing avoid, for sake of arguement, 3 foods.  You might have the standard elimination diet be no apples, onions or lactose/dairy.  Then for lets say 2 weeks they follow that standard elimination diet.  Then for the other two weeks they do the elimination diet based on the tests.  Flip a coin (randomize) which diet they do first and use one of the standard evaluation of symptom questionaires other studies use.  So maybe 4 weeks of diet and do the evaluation 1X per week. (or may do a daily symptom diary or whatever you think would be a good evaluation)

 

It may be worth having them do their regular diet and 2 weeks of the survey before the testing so you have their baseline.

 

Now you could also do it with eliminating safe for IBS foods so you don't expect any benefit based off the Low Fodmap Diet.  But I think using the low Fodmap (even if only partial) as a place to compare to, you tie into some of the current thinking on IBS diet that is out there even if you don't have them do the full Low Fodmap as it sounds like you aren't having them eliminate a lot of different foods at a time.

 

A lot of which way to go will depend on study size.  If I was only doing a small sample as another proof of concept I might do the eliminate 3 foods that are typically safe for IBSers so there is more likely to be a difference.  But in a larger study if you show that you get a lot more benefit from eliminating foods from the test compared to random eliminate these if you have IBS foods, that would tend to make me sit up and take notice.  Especially since something like the low fodmap diet when done in full elminates a lot of foods and many people find it difficult to do the whole thing, although some people do over time add foods back to see what of the long list they can tolerate.


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#12 DermDoc

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Posted 10 April 2013 - 06:23 AM

Kathleen M.,

 

Thank you for you insight and suggestions.  A cross-over study comparing a low fodmap diet vs. targeted elimination of patch test-positive foods I think would be a great comparison.  I will be engaging university-based GI departments for the validation studies and will suggest this (and include you in acknowledgments!).  The difficult part would be to blind subjects as to what they're eating.  Unless they are given all foods they can eat for several weeks, it would be fairly impossible.  Taking photos would not help as many of the allergens are additives such as preservatives (sodium benzoate, octyl gallate, citric acid, etc.) or flavorings (strawberry aldehyde, for example); label reading is just as important as choosing the bulk foods that can be eaten.

 

For now, my center is offering food patch testing to about 120 foods/food additives known to cause type 4 skin reactions and we have Investigational Review Board approval to collect data from patients who have positive patch tests and then follow an avoidance diet.  



#13 Kathleen M.

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Posted 10 April 2013 - 09:06 AM

A lot depends on cost.

 

Free range with verification is going to be cheaper than full blind clinical research kitchen makes all the food type of study.

 

I think if you do get to a real blinded study (like a standard diet with a cereal bar for desert one with the strawberry flavor and one without) you are probably going to need to do it for one or two additives. 

 

May also be worth seeing if any of the additive can be easily detected in the people for some of the verification.  They did that with a free range  Mediterranean diet from Spain, I think.  They could measure metabolites of the nuts and olive oil they were asking people to eat to see if they were eating enough to have the effects they were looking for.

 

With photo log of food they can also document the ingredient lists and for resaurant food you can probably get a feel for if it is likely to have the eliminated additive or not.  No strawberry flavoring with some red fruit dessert may be a "red flag" they weren't compliant. :)


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