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The aim of this thesis is to evaluate and optimise current pharmacotherapeutic options in rhinosinusitis. There is often a marked variation in treatment response in those afflicted with chronic rhinosinusitis, both within and between patients, attributable in part to different disease phenotypes/endotypes, poor awareness of treatment optimization options, and trivialization of symptoms by patients and physicians. Characteristically, these factors contribute to a typical remitting and relapsing disease course. The objectives of this work are to improve the therapeutic index and reach of commonly used medications by boosting efficacy whilst reducing concomitant side effects. The third chapter explores the use of initial oral steroids in patients with chronic rhinosinusitis and nasal polyposis, focusing on the role of the ostiomeatal complex in the perpetuation of disease symptoms. Often a short course of oral steroids is used in patients with moderate to severe disease to achieve initial control before maintenance with intranasal steroids. This is termed as a ‘medical polypectomy’ and anecdotally is commonly used in patients with chronic rhinosinusitis with nasal polyposis (CRSwNP). However, the evidence for its efficacy is tenuous and there are no data to evaluate if it indeed re-establishes ostiomeatal sinus complex drainage which is a condicio sine qua non of ensuring long-term symptom resolution. Further, it is known that monotherapy with nasal steroids may result in loss of symptom control. We have therefore in a double-blind placebo controlled trial (Chapter 4) evaluated the effect of this initial induction with oral steroids on subsequent sequential intranasal therapy. Perhaps, however, more crucially we have for the first time comprehensively addressed the safety of both oral and topical steroids in patients with CRSwNP who have other concomitant steroid-dependent illnesses like asthma and COPD. A particularly refractory subset of those with CRSwNP also have aspirin intolerance and asthma. While recent guidelines have recommended more aspirin challenge testing in these patients, it is unclear what the significance of a positive test is in the absence of overt clinical symptoms or in patients with only moderate disease. This is addressed in Chapter 5, as this significant phenotype of aspirin intolerant rhinosinusitis need close monitoring, dose optimization, polytherapy, and in selected cases may be suitable for aspirin desensitization. Penultimately, we evaluate in a double-blind placebo controlled trial (Chapter 6) the tachyphylaxis and rebound congestion that blights the medium to long-term use of sympathomimetic nasal decongestant sprays like oxymetazoline and if this can be reversed by the concomitant use of nasal steroids. We also characterized nasal blood flow as an outcome to evaluate in these patients and its relation to other rhinological outcome measures (Chapter 7).

Asthma is defined as reversible airflow obstruction and an estimated 1-in-3 Canadians will be diagnosed over their lifetime. Many clinical phenotypes of asthma exist, but allergic asthma is the most common presentation. Despite effective therapies, approximately 65% of Canadian asthmatics have poorly controlled disease. Thus, there remains pressing need to develop disease modifying therapies. Allergen-specific immunotherapy (SIT) is a disease-modifying therapy for allergic disease that consists of repeatedly administering doses of allergen, to an allergic individual; over 100 years of clinical use, SIT has been demonstrated to reduce symptoms of disease both during and after cessation of therapy. Widespread clinical uptake of SIT has been limited by the risk of developing anaphylaxis as a response to therapy. Peptide immunotherapy is a derivation of SIT, that attempts to retain the disease-modifying benefits, while lessening the risk of anaphylaxis, by treating subjects with allergen-derived T-cell peptide epitopes. Peptide immunotherapy has been demonstrated to reduce symptoms of allergic disease in treated subjects; however, it remains unknown how administration of a single (or several) T-cell epitopes can modulate immune responses to entire complex allergens. Additionally, how genetic diversity in peptide epitope presentation effects the development of immune tolerance is unknown. In this thesis, we sought to characterize these mechanisms of peptide immunotherapy; the hypothesis was, “The induction of immunosuppression by peptide immunotherapy involves the infectious spread of tolerance beyond the treatment epitope, and is dependent upon treatment peptide dose and affinity to MHC”. Through the definition of these mechanistic traits we hoped to expedite and inform the design of future peptide based therapeutics. The studies presented within this thesis examine the topic of immune modulation of allergic disease in mouse models, and have focused upon broadly pertinent characteristics of immune modulation, such as the number, dose and affinity of immunomodulatory epitopes. / Thesis / Doctor of Philosophy (PhD) / Asthma is a disease of the airways that can cause difficulties in breathing. In some people, asthma develops because their immune system reacts in an uncontrolled manner to common environmental proteins, called allergens. Whole allergen immunotherapy is a treatment for asthma, where asthmatic people are injected with doses of allergen until their immune system no longer responds to (or ‘tolerates’) the allergen. In some people, injection of allergen can lead to a life-threatening immune response known as ‘anaphylaxis’. Peptide-immunotherapy is a form of whole allergen immunotherapy where people are given small fragments of the allergen (a ‘peptide’) rather than the whole allergen. The benefit of peptide immunotherapy is that the treatment peptides are too small to cause anaphylaxis, but remain large enough to teach the immune system. In this thesis, we examined how treatment with small peptides teaches the immune system to tolerate the larger and more complex whole allergen.

Diabetes mellitus Typ 1 und Allergien vom Soforttyp gehören zu den häufigsten chronischen Erkrankungen des Kindes- und Jugendalters. Diabetes mellitus Typ 1 wird verursacht durch eine autoimmune Zerstörung der Beta-Zellen des Pankreas. Aus immunologischer Sicht wird dieser Prozess durch TH1-Zellen dominiert. Im Gegensatz dazu wird vermutet, dass Allergien vom Soforttyp, wie die allergische Rhinitis, das allergische Asthma und die allergische Urtikaria mit TH2-Zellen assoziiert seien. Die Hypothese, dass TH1- und TH2-Zellen sich gegenseitig in ihrer Aktivität hemmen, ist immer noch gültig. Ziel unserer Fall-Kontroll-Studie war es, die Assoziation zwischen Typ 1 Diabetes und IgE-vermittelten Allergien zu untersuchen. Zur Prüfung unserer Forschungshypothese wurden ein standardisierter, evaluierter Fragebogen sowie verschiedene Laboranalysen herangezogen. Es konnte gezeigt werden, dass Diabetes mellitus Typ 1 mit einem erhöhten Risiko für das gleichzeitige anamnestische Vorliegen IgE-vermittelter allergischer Symptome assoziiert sein könnte. Somit konnten wir bestätigen, dass die noch heute weit verbreitete TH1/TH2-Hypothese eine Vereinfachung tatsächlich viel komplizierterer immunologischer Vorgänge darstellt. Um diese Assoziation im Detail zu prüfen, bedarf es jedoch weiteren populationsbasierten epidemiologischen Studien.:I. Bibliographische Beschreibung 7 II. Abkürzungsverzeichnis 9 1. Einführung 11 1.1 Epidemiologie und Pathogenese des Diabetes mellitus Typ 1 11 1.2 Epidemiologie und Pathogenese von Allergien vom Soforttyp 13 1.3 Aktueller Forschungsstand zum Thema 14 2. Das Promotionsprojekt 17 2.1 Forschungshypothese und Fragestellung 17 2.2 Patienten und Methoden 17 2.3 Statistische Datenauswertung 19 2.4 Ergebnisse 20 2.5 Einordnung in den aktuellen wissenschaftlichen Diskurs 23 3. Publikationsmanuskript 29 4. Zusammenfassung der Arbeit 43 5. Literaturverzeichnis 47 III. Erklärung über die eigenständige Abfassung der Arbeit 55 IV. Curriculum Vitae 57 V. Liste der Veröffentlichungen 59 VI. Danksagung 61

Allergic reactions are mainly mediated by the interactions between the IgE and its ligands, amongst them CD23 and CD21 in what is termed the IgE network. CD23 is involved in upregulating IgE expression by forming a trimolecular complex with CD21 and IgE on the B-cell surface, resulting in the specific activation of IgE-positive B cells. CD21 also interacts with C3d and is a bridge between the innate and the immune system. A crystal structure of the interaction has been solved (Szakonyi et al., 2001) but was controversial because it contradicted previous biochemical analyses. The aims of this thesis were to use various biophysical techniques to study the interactions between the molecules in the IgE network and its possible inhibition. Part 1: Characterisation of a phage display-derived peptide that inhibit IgE binding to CD23 A peptide was previously derived using phage display technology and tested for binding ability to CD23 using SPR and ITC. Subsequent NMR experiments were performed to identify the binding site, followed by characterization of its derivatives. Crystallisation of CD23 with the peptide and soaking with its truncated tripeptide, NWP, were also attempted. Part 2: Characterisation of CD23 and its interaction with its ligands X-ray crystallography was undertaken to solve the structure of derCD23 in complex with a phage display-derived peptide (Part1) followed by crystal soaking with a truncated tripeptide, NWP. However, a reproducible, high-resolution wild type derCD23 structure was determined at 1.9 Å. A comparison of the binding behaviour between the monomeric derCD23 and a trimeric CD23 construct was carried out in order to see the effect of oligomerisation upon IgE binding. Using the known interaction map as well as a crystal structure, the possible interacting residues between CD23 and IgE were examined. The characterisation of the CD23/CD21 interaction was continued from previous efforts in order to confirm that the binding epitope of CD23 for CD21 lies within the C-terminus of CD23. Characterisation of the interactions of CD23/IgE/FcεRI was performed to examine these multimolecular interactions and possible regulatory mechanisms in mast cell degranulation. It was shown that CD23 can form multimeric complexes with IgE-Fc that bind to FcεRI with higher apparent affinity than IgE-Fc alone, which may lead to increases in mast cell degranulation. It was also found that the IgE bound on FcεRI still binds to CD23 although with a lower binding capacity, presumably due allosteric changes. The binding of CD23 with a monoclonal antibody IDEC-152 was also characterised using SPR and NMR spectroscopy. It was proposed that IDEC-152 might interfere with the trimerisation site of CD23 thus reducing its affinity for IgE. A thermofluor assay was developed and optimised for potential screening of compounds that bind to derCD23 using a qPCR machine, which may be useful to screen compounds that bind to CD23 as part of future drug discovery project. Crystallisation of the derCD23/CD21 and IgE/triCD23/CD21 complexes was also attempted as part of ongoing crystallisation projects. Part 3: The interaction between C3d and CD21 The interaction between C3d and CD21 is believed to be a bridge between the innate and adaptive immune response, and is thought to be pivotal in the initiation of autoimmune disease. Following from previous studies on this interaction, further characterisations were performed using NMR and ITC to confirm the involved sites on CD21 (SCR1-2) in binding to C3d. Several potential salt bridges have been identified so far, allowing a high-resolution docked structure of the C3d/CD21 complex.