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Toward precision medicine and health: Opportunities and challenges in allergic diseases

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Precision medicine (also called personalized, stratified, or P4 medicine) can be defined as the tailoring of preventive measures and medical treatments to the characteristics of each patient to obtain the best clinical outcome for each person while ideally also enhancing the cost-effectiveness of such interventions for patients and society. Clearly, the best clinical outcome for allergic diseases is not to get them in the first place. To emphasize the importance of disease prevention, a critical component of precision medicine can be referred to as precision health, which is defined herein as the use of all available information pertaining to specific subjects (including family history, individual genetic and other biometric information, and exposures to risk factors for developing or exacerbating disease), as well as features of their environments, to sustain and enhance health and prevent the development of disease. In this article I will provide a personal perspective on how the precision health–precision medicine approach can be applied to the related goals of preventing the development of allergic disorders and providing the most effective diagnosis, disease monitoring, and care for those with these prevalent diseases. I will also mention some of the existing and potential challenges to achieving these ambitious goals.

Section snippets

General principles of precision medicine and health

One piece of evidence indicating that a concept has become mainstream is when it is widely used to sell products directly to physicians and consumers. For years, various commercial enterprises have been offering to sell individuals an analysis of their “genomes” (these analyses typically are not based on sequencing the full genome but on analyzing thousands of single nucleotide polymorphisms in individual genes) to trace their ancestry or, initially at least, even to permit them to assess their

Allergic disorders: A unique opportunity for the development of precision medicine and precision health

In the asthma field several recent studies have provided data indicating that proper selection of patients based on their clinical characteristics, including certain readily measurable features of their disorder (these can be called, generically, biomarkers), can identify subsets of patients more likely to respond favorably to biologics that impair the functioning of pathways implicated in the development of airway pathology in such subjects (for a recent review, see Berry et al20). In such

Preventing disease development

There is strong evidence that hereditary factors contribute to the propensity to allergic diseases.44, 45, 46 Therefore an effective way to reduce the incidence of allergic diseases in your children would be to select your spouse carefully, avoiding candidates who have a strong family history of allergic disorders. Such approaches already are being taken, along with adoption, to avoid the transmission of severe hereditary disorders that are based on the deleterious effects of single affected

Avoidance

Although the scrupulous avoidance of offending allergens is a mainstay of the management of allergic disorders,71 as noted above, this approach can be personalized, at least in principle, by using appropriate testing to carefully establish which allergens must be avoided and by defining the threshold amounts of such allergens individual subjects can ingest without triggering clinical signs and symptoms. Because various factors can alter one's threshold for clinically reacting to an offending

Cure

Allergen-specific immunotherapy has shown considerable success in modifying underlying disease in certain settings, notably in the setting of allergic rhinitis,74, 75, 76 and a number of promising approaches for developing novel immunotherapy vaccines are under investigation.77 Although determining whether successfully treated patients are truly cured of their disease depends on how one defines cure, many patients can experience long-term relief of symptoms, and their state of clinical

Disease monitoring in allergic disorders

If one unmet need in clinical allergy/allergology is to identify approaches that can accurately predict responsiveness to SIT, another is to develop disease-monitoring tests that can assess the extent to which such SIT is working in patients undergoing treatment. In the case of food allergies, initial studies indicate that some patients treated with oral immunotherapy (OIT) can achieve sustained clinical nonreactivity to a maintenance dose of the offending allergen, whereas others do not.78, 79

Toward precision medicine and health in the field of allergy

Providing the best possible personalized care for patients with allergic diseases and helping those at risk to avoid such disorders will be ongoing long-term efforts. However, it is possible to think now about general approaches for achieving those goals and to consider some broad principles for practicing precision medicine in the field of allergy (Table I). Notably, each of the topics listed in Table I has its own set of challenges.

For example, there is much current interest in defining

Clinical implications and future directions

It is difficult to imagine a more promising and exciting time in the history of clinical allergy/allergology. There can be no doubt that we face a big challenge, in that the factors which have contributed to the striking increase in the prevalence of allergic diseases since the late 19th century are probably both diverse in their nature and complex in their interactions.88 The good news is that there has been a marked increase in the power of new scientific and bioinformatics tools that can be

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      During the process, it becomes necessary to standardize the diagnostic criteria and classification rule among different institutions to help advance research on pathophysiology and evaluate treatment efficacy. In addition, stratification of healthy individuals (selecting high-risk groups of “potential patients”) is also required to implement precision medicine11 and preemptive therapy, which will be described in the next section. Furthermore, the utilization of artificial intelligence (AI) in “big data” analysis and standardizing phenotypes in model organisms need to be promoted.

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    Series editors: Donald Y. M. Leung, MD, PhD, and Dennis K. Ledford, MD

    Supported by National Institutes of Health grants U19AI104209 and R01AR067145 and the Department of Pathology of Stanford University.

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