Updating the CoFAR Grading Scale for Systemic Allergic Reactions in Food Allergy

Re-evaluating treatment success in trials of peanut oral-immunotherapy: impact of different definitions on efficacy outcomes

PURPOSE OF REVIEW

Allergen immunotherapy (AIT) is increasingly popular as a treatment strategy for food allergy. Unfortunately, there is significant heterogeneity in reported outcomes, specifically in the dose-thresholds selected for evaluation and the symptoms used to define a "tolerated dose". These considerations are often investigator-driven and do not consider patient perspectives.

RECENT FINDINGS

A systematic review by the EAACI CO-FAITH taskforce recently flagged the need to better standardize and harmonize outcomes used in clinical trials of food-AIT. Using less objective symptoms to define dose-limiting symptoms can underestimate the reaction threshold determined at baseline food challenge. As a consequence, this can overestimate the efficacy of food-AIT by 15%. In this review, we perform an individual patient data (IPD) meta-analysis using data from three randomized-controlled trials and one real-world registry, to evaluate how the definition of dose "tolerance" impacts upon reported desensitization rates.

SUMMARY

This analysis provides insight into how clinical efficacy rates for food-AIT are impacted by using different dose thresholds and definitions for when a dose might be consider tolerated. Using more patient-centric outcomes may be a more useful metric to harmonize reporting of outcomes and inform clinical practice, paving the way towards reaching a consensus on outcome reporting in trials of food-AIT.

Peanut challenges prior to oral immunotherapy demonstrate high tolerance rates in selected patients

Background

Peanut oral immunotherapy (pOIT) protocols typically remain below the threshold for reaction during the initial dose escalation (IDE) day. However, some patients may have higher thresholds for reaction or may not have an ongoing peanut allergy.

Objective

We sought to characterize the response to an accelerated initial dose escalation (A-IDE) for qualifying low-risk peanut-allergic patients younger than 4 years in which IDE progressed to a full peanut oral food challenge as tolerated.

Methods

Records of 76 pOIT patients younger than 4 years were reviewed. Those with history of peanut reaction with peanut allergy testing of less than 95% positive predictive value for failed oral food challenge were offered an A-IDE. A-IDE proceeded stepwise until patients refused dosing, any reaction occurred, or they tolerated the challenge (cumulative dose: 4000 mg peanut protein). If the A-IDE was not tolerated, patients completed pOIT.

Results

From April 2022 to February 2024, 16 patients participated in an A-IDE. Eleven (68.8%) tolerated the 4000 mg cumulative dose, demonstrating resolution of their peanut allergy. The remaining had mild symptoms not requiring epinephrine. Mean pOIT starting dose following A-IDE was 450 mg (vs 25 mg in standard pOIT). Maintenance dosing was reached with a mean of 5.2 visits (vs 9.7 in standard pOIT).

Conclusions

Nearly 70% of low-risk patients younger than 4 years with previous diagnosis of peanut allergy tolerated a full peanut serving when initiating pOIT. This indicates the importance of diagnostic peanut challenge to selected patients before initiating OIT.

A Guide to Pediatric Antibiotic Allergy Testing: A Report From the US Drug Allergy Registry

Pediatric antibiotic labels are common, and unnecessary antibiotic avoidance is associated with negative personal and public health outcomes; as a result, there is an increasing emphasis on the importance of pediatric antibiotic allergy evaluations. Different testing strategies have been advised, including skin testing and challenge testing with varied doses and duration. Established consensus testing protocols are lacking. The US Drug Allergy Registry Pediatrics (USDAR-Peds) is a multisite prospective study designed for epidemiology and outcome evaluations of pediatric drug hypersensitivity reactions. Interpretation of multisite data requires a uniform clinical approach, and the USDAR-Peds standardized protocols were developed in response to this need. This rostrum aims to provide a rationale and framework for standardization for pediatric antibiotic allergy protocols and assessment of positive reactions through a pediatric-specific adaptation of the USDAR immediate reaction grading scale to create consistency for multisite research collaboration efforts such as USDAR-Peds.

Food allergy endotypes revisited

In the last century, food allergy has become recognized as an increasingly prevalent and heterogeneous condition. Advances in biomedical technology have revealed complex genetic, environmental, immune, and metabolic pathways underlying the pathogenesis of food-allergic disorders. These findings permit classification of distinct food allergy endotypes with unique pathophysiologic features. In this review, we suggest that these endotypes of food-allergic disorders should be defined on the basis of (1) whether or not the allergic antibody IgE plays an essential role in disease pathogenesis, (2) the molecular features of the allergen (protein vs carbohydrate), and (3) the molecular markers associated with prognosis, severity, or clinical presentation. Beyond these broad categories, additional subtypes with unique mechanistic characteristics are discussed.

Hazelnut Oral Immunotherapy Desensitizes Hazelnut But Not Other Tree Nut Allergies (Nut CRACKER Study)

BACKGROUND

Data on oral immunotherapy (OIT) for hazelnut allergy is limited and its potential to cross-desensitize for other nuts is unknown.

OBJECTIVE

To study the efficacy and safety of hazelnut OIT in desensitizing to hazelnut and additional tree nuts.

METHODS

This was a prospective observational study of 30 hazelnut-allergic patients aged 4 years or older who underwent hazelnut OIT. Full desensitization (4,000 mg protein) rates were compared with those of 14 observational controls, and immunologic changes during OIT were measured. We determined cross-desensitization in cases of walnut and cashew co-allergy (n = 12). Inhibition of IgE binding to walnut by hazelnut was evaluated by ELISA in a separate set of dual walnut-hazelnut allergic patients.

RESULTS

The rate of full hazelnut desensitization following OIT was 96.7% (29 of 30 patients) compared with 14.3% (two of 14) in controls (odds ratio = 25.7; 95% CI, 3.7-178.7; P < .001). Five patients (16.7%) were treated with injectable epinephrine for home reactions. Hazelnut skin prick test and specific IgE to hazelnut and its main components, Cor a 9, 14 and 16, decreased whereas specific IgG4 increased during OIT. A maintenance dose of 1,200 mg hazelnut protein was sufficient to maintain full desensitization. No cross-desensitization was noted in dual hazelnut-cashew allergic patients (n = 6). In dual hazelnut-walnut allergic patients, an increase in the walnut eliciting dose was observed in two of six patients (33.2%) (to 1,200 and 4,200 mg, respectively). Similarly, by cross-inhibition ELISA, hazelnut competed for IgE-binding to walnut in five of 25 (20%) hazelnut-walnut co-allergic patients (20%).

CONCLUSIONS

Hazelnut OIT is highly effective, with a safety profile similar to that of OIT to other nuts. Cross-desensitization to walnut and cashew is unlikely.

Advances in Mechanisms of Anaphylaxis in Wheat Allergy: Utility of Rodent Models

Wheat is a staple and nutritious food that is consumed globally. However, it is identified as a major allergenic food because of its capacity to trigger life-threatening systemic anaphylaxis. The specific mechanisms that underlie this systemic anaphylaxis in wheat allergy are incompletely understood. As a result, several rodent models have been developed to study anaphylaxis in wheat allergies. In this paper, we have conducted a comprehensive review of wheat-induced anaphylaxis using Google Scholar and PubMed databases with relevant keywords. The following objectives were addressed: (1) to determine the complexity of wheat-induced anaphylaxis; (2) to summarize the role of genetic susceptibility in wheat anaphylaxis; (3) to identify the environmental factors involved in the development of wheat anaphylaxis; (4) to map the current status of mechanisms involved in wheat anaphylaxis; (5) to identify the approaches, strengths, and limitations of rodent models of wheat anaphylaxis; and (6) to identify challenges and opportunities in this area of science. Our findings provide a comprehensive updated critical resource for the future research agenda in wheat allergy-associated anaphylaxis, particularly using rodent models as attractive pre-clinical tools.

Anaphylaxis severity grade, during oral food challenges, assessed by five different classifications

BACKGROUND

While the definition of anaphylaxis is clear, its grade of severity remains a subject of debate. The objective of this study was to evaluate the possible discrepancies in the severity scoring system for anaphylaxis in patients with a positive food challenge (OFC), differentiating anaphylactic and non-anaphylactic reactions, using the WHO for the 11th version of the International Classification of Diseases (ICD-11) as the main reference.

METHODS

We conducted a retrospective observational study at the University Hospital of Montpellier, France, including patients with a positive food OFC between 2018 and 2022. We classified the severity of each reaction based on 5 different classifications. We also compared patients presenting an anaphylactic versus a non-anaphylactic reaction during the OFC in terms of symptoms and therapeutic approach.

RESULTS

235 patients presented a positive OFC between January 2018 and December 2022: 143 (60.9%) suffered from anaphylaxis, according to the ICD-11 classification. When comparing the different classifications, a complete concordance was recorded in 8 patients (5.6%) only. All classifications showed a good sensitivity (99.3%-100%), but different specificity (67.4%-93.5%), and discrepancies between them were shown in most patients. Respiratory and gastrointestinal symptoms were significantly more frequent in the anaphylaxis group. Adrenaline was injected in only 47.6% of patients suffering from anaphylaxis, even in a specialized setting.

CONCLUSION

Our work highlights the need to refine the different scoring systems and, even better, to disseminate unified diagnostic criteria, such as the ICD-11 ones, to avoid the underdiagnosis of anaphylactic reactions and ensure appropriate management for all allergic patients.

Clinical and immunological outcomes after randomized trial of baked milk oral immunotherapy for milk allergy

BACKGROUNDCow's milk (CM) allergy is the most common food allergy in young children. Treatment with oral immunotherapy (OIT) has shown efficacy, but high rates of adverse reactions. The aim of this study was to determine whether baked milk OIT (BMOIT) could reduce adverse reactions while still inducing desensitization, and to identify immunological correlates of successful BMOIT.METHODSThis phase II, randomized trial evaluated the safety and efficacy of BMOIT in milk-allergic children 3-18 years old. After the initial placebo-controlled first year of treatment, placebo-treated participants crossed over to active BMOIT. Double-blind, placebo-controlled oral food challenges (OFCs) were conducted with BM after year 1 and to both BM and unheated milk (UM) after year 2. IgG and IgE antibodies were measured along with CM-specific (CM+) CD4+ memory T cell populations, profiled using flow cytometry and scRNA-Seq.RESULTSTwenty-one of 30 (70%) reached the primary endpoint of tolerating 4044 mg of BM protein at month 24, and 11 of 30 tolerated 2000 mg or more of UM protein. Dosing symptoms were common, but more than 98% were mild, with no severe reactions. Immunological changes associated with desensitization included increased CM IgG4, CM+ FOXP3+ cells, and Tregs and corresponding decreases in CM IgE, CM+ Th2A cells, and CD154+ cells. T cell and antibody measurements were combined to build a model that predicted UM OFC outcomes.CONCLUSIONBMOIT was well tolerated and induced desensitization to BM and UM. This desensitization corresponded to redistribution within antigen-specific antibody and T cell compartments that provided insight into the mechanistic changes that occur with OIT treatment.TRIAL REGISTRATIONClinicalTrials.gov NCT03462030.FUNDING: Myra Reinhardt Family Foundation (grant number 128388), NIH/NIAID (U19AI135731, T32AI125179, S10OD025052).

Egg allergen-specific T-cell and cytokine responses in healthy and egg-allergic children naturally tolerating baked egg

BACKGROUND

Type 1 regulatory T (Tr1) cells are critical players in maintaining peripheral tolerance, by producing high IL-10 levels in association with inducible T-cell co-stimulator (ICOS) expression. Whether these cells play a role in naturally acquired baked egg tolerance is unknown.

OBJECTIVES

Evaluate frequencies of egg-responsive Tr1 and Th2 cells in egg-allergic children that naturally acquired baked egg tolerance (BET) versus non-egg-allergic (NEA) children.

METHODS

Peripheral blood mononuclear cells from 70 natural BET and 15 NEA children were stimulated for 7 days with ovalbumin and ovomucoid. By flowcytometry, egg-responsive Tr1 cells were identified by co-expression of CD49b and LAG3, and Th2 cells by expression of CD49b but absence of LAG3. Seven-day cultured supernatant was analyzed for Th1, Th2, Tr1, and Th17 cytokines by MSD.

RESULTS

Natural BET children had a higher percentage of egg-responsive Th2 cells vs. NEA children (6.75% vs. 10.35%, p = .006). No significant difference was found in frequencies of egg-responsive Tr1 cells between NEA and natural BET children (11.40% vs. 12.55%, p = .42), although Tr1-related IL-10 and IL-21 production was higher in BET children. Interestingly, egg-responsive Tr1 cells from NEA children expressed higher ICOS levels vs. natural BET children (97.90 vs. 88.20, p < .0001). Supernatant from natural BET children showed elevated levels of Th2 cytokines IL-5, IL-9 and IL-13 and Th17 cytokine IL-17A.

CONCLUSION

Natural BET children maintain increased egg-specific Th2 responses, along with comparable proportions of egg-responsive Tr1 cells exhibiting higher IL-10 but lower ICOS expression in comparison with NEA children.

The conformational epitope of Ara h 5 was crucial to the severe reactivity of peanut allergy

Conformational epitopes are associated with the development of food allergic tolerance and the severity of food allergy. Peanut can trigger severe anaphylactic reactions, however, the reason behind the severe allergic reactions caused by peanut remains unexplained. The purpose of this article was to provide an explanation for the severe allergy caused by peanut, focusing on the conformational epitopes of Ara h 5 and Ara h 8 allergens that exhibit cross-reactivity with asthma reactions. Ara h 5 and Ara h 8 proteins were prepared by an Escherichia coli expression system. IgE reactivity of 37 patients with allergy toward Ara h 5 and Ara h 8 allergens was assessed by using IgE-binding assays, dot blot and western blot. The allergenicity of Ara h 5 and Ara h 8 protein was analysed in mouse model. Conformational IgE epitopes of Ara h 5 was identified using phage peptide library and the Pepitope Server. Compared to Ara h 8, the conformational epitope of Ara h 5 protein was crucial in the process of sensitization. Ara h 5 showed a stronger IgE reactivity and the ability to induce β-hexosaminidase release. Ara h 5 caused more severe lung inflammation than Ara h 8 protein. While Ara h 8 caused more severe intestinal inflammation than Ara h 5. The results showed that the conformational epitope sequences of Ara h 5 were WETIYSR and FHWWYLK. The results provide a theoretical basis for the production of hypoallergenic peanut protein and the immunotherapy of peanut allergy.

Utility of epitope-specific IgE, IgG4, and IgG1 antibodies for the diagnosis of wheat allergy

BACKGROUND

The bead-based epitope assay has been used to identify epitope-specific (es) antibodies and successfully used to diagnose clinical allergy to milk, egg, and peanut.

OBJECTIVE

We sought to identify es-IgE, es-IgG4, and es-IgG1 of wheat proteins and determine the optimal peptides to differentiate wheat-allergic from wheat-tolerant using the bead-based epitope assay.

METHODS

Children and adolescents who underwent an oral food challenge to confirm their wheat allergy status were enrolled. Seventy-nine peptides from α-/β-gliadin, γ-gliadin, ω-5-gliadin, and high- and low-molecular-weight glutenin were commercially synthesized and coupled to LumAvidin beads (Luminex Corporation, Austin, Tex). Machine learning methods were used to identify diagnostic epitopes, and performance was evaluated using the DeLong test.

RESULTS

The analysis included 122 children (83 wheat-allergic and 39 wheat-tolerant; 57.4% male). Machine learning coupled with simulations identified wheat es-IgE, but not es-IgG4 or es-IgG1, to be the most informative for diagnosing wheat allergy. Higher es-IgE binding intensity correlated with the severity of allergy phenotypes, with wheat anaphylaxis exhibiting the highest es-IgE binding intensity. In contrast, wheat-dependent exercise-induced anaphylaxis showed lower es-IgG1 binding intensity than did all the other groups. A set of 4 informative epitopes from ω-5-gliadin and γ-gliadin were the best predictors of wheat allergy, with an area under the curve of 0.908 (sensitivity, 83.4%; specificity, 88.4%), higher than the performance exhibited by wheat-specific IgE (area under the curve = 0.646; P < .001). The predictive ability of our model was confirmed in an external cohort of 71 patients (29 allergic, 42 nonallergic), with an area under the curve of 0.908 (sensitivity, 75.9%; specificity, 90.5%).

CONCLUSIONS

The wheat bead-based epitope assay demonstrated greater diagnostic accuracy compared with existing specific IgE tests for wheat allergy.

AAAAI-EAACI PRACTALL: Standardizing oral food challenges-2024 Update

This common statement of the American Academy of Allergy, Asthma and Immunology (AAAAI) and The European Academy of Allergy and Clinical Immunology (EAACI) provides an update of the 2012 published guidelines on food challenges. The guidelines equally address food challenges in the research and the clinical settings. They first address the diagnostic tests which can guide the decision to conduct a challenge. Safety of food challenges is prime, and the various procedures and safety issues as well as medications potentially involved in challenges are extensively discussed. Challenges are suggested to be conducted with semi-logarithmic incremental doses based on the protein content, typically for IgE-mediated food allergy with intervals of 20-30 min between doses. Specific protocols for other types of reactions such atopic dermatitis or gastrointestinal food allergy are detailed separately. Proper stopping criteria are essential in order to reduce the risk of false-positive diagnoses, but also severe reactions. The guidelines recommend criteria based on "go on," "stop," or "observation." These revised guidelines will clearly provide much needed guidance for food challenges in the research and clinical settings. They will continue to evolve with new diagnostic tests or new needs in the field of food allergy.

Management of Refractory Anaphylaxis: An Overview of Current Guidelines

In this review, we compare different refractory anaphylaxis (RA) management guidelines focusing on cardiovascular involvement and best practice recommendations, discuss postulated pathogenic mechanisms underlining RA and highlight knowledge gaps and research priorities. There is a paucity of data supporting existing management guidelines. Therapeutic recommendations include the need for the timely administration of appropriate doses of aggressive fluid resuscitation and intravenous (IV) adrenaline in RA. The preferred second-line vasopressor (noradrenaline, vasopressin, metaraminol and dopamine) is unknown. Most guidelines recommend IV glucagon for patients on beta-blockers, despite a lack of evidence. The use of methylene blue or extracorporeal life support (ECLS) is also suggested as rescue therapy. Despite recent advances in understanding the pathogenesis of anaphylaxis, the factors that lead to a lack of response to the initial adrenaline and thus RA are unclear. Genetic factors, such as deficiency in platelet activating factor-acetyl hydrolase or hereditary alpha-tryptasaemia, mastocytosis may modulate reaction severity or response to treatment. Further research into the underlying pathophysiology of RA may help define potential new therapeutic approaches and reduce the morbidity and mortality of anaphylaxis.

Fermented Gracilaria lemaneiformis polysaccharides alleviate food allergy by regulating Treg cells and gut microbiota

Food allergy has a significant impact on the health and well-being of individuals, affecting both their physical and mental states. Research on natural bioactive compounds, such as polysaccharides extracted from seaweeds, holds great promise in the treatment of food allergies. In this study, fermented Gracilaria lemaneiformis polysaccharides (F-GLSP) were prepared using probiotic fermentation. Probiotic fermentation of Gracilaria lemaneiformis reduces the particle size of polysaccharides. To compare the anti-allergic activity of F-GLSP with unfermented Gracilaria lemaneiformis polysaccharides (UF-GLSP), an OVA-induced mouse food allergy model was established. F-GLSP exhibited a significant reduction in OVA-specific IgE and mMCP levels in allergic mice. Moreover, it significantly inhibited Th2 differentiation and IL-4 production and significantly promoted Treg differentiation and IL-10 production in allergic mice. In contrast, UF-GLSP only reduced OVA-specific IgE and mMCP in the serum of allergic mice. Furthermore, F-GLSP demonstrated a more pronounced regulation of intestinal flora abundance compared to UF-GLSP, significantly influencing the populations of Firmicutes, Bacteroidetes, Lactobacillus, and Clostridiales in the intestines of mice with food allergy. These findings suggest that F-GLSP may regulate food allergies in mice through multiple pathways. In summary, this study has promoted further development of functional foods with anti-allergic properties based on red algae polysaccharides.

A randomized double-blinded trial to assess recurrence of systemic allergic reactions following COVID-19 mRNA vaccination

BACKGROUND

Systemic allergic reactions (sARs) following coronavirus disease 2019 (COVID-19) mRNA vaccines were initially reported at a higher rate than after traditional vaccines.

OBJECTIVE

We aimed to evaluate the safety of revaccination in these individuals and to interrogate mechanisms underlying these reactions.

METHODS

In this randomized, double-blinded, phase 2 trial, participants aged 16 to 69 years who previously reported a convincing sAR to their first dose of COVID-19 mRNA vaccine were randomly assigned to receive a second dose of BNT162b2 (Comirnaty) vaccine and placebo on consecutive days in a blinded, 1:1 crossover fashion at the National Institutes of Health. An open-label BNT162b2 booster was offered 5 months later if the second dose did not result in severe sAR. None of the participants received the mRNA-1273 (Spikevax) vaccine during the study. The primary end point was recurrence of sAR following second dose and booster vaccination; exploratory end points included biomarker measurements.

RESULTS

Of 111 screened participants, 18 were randomly assigned to receive study interventions. Eight received BNT162b2 second dose followed by placebo; 8 received placebo followed by BNT162b2 second dose; 2 withdrew before receiving any study intervention. All 16 participants received the booster dose. Following second dose and booster vaccination, sARs recurred in 2 participants (12.5%; 95% CI, 1.6 to 38.3). No sAR occurred after placebo. An anaphylaxis mimic, immunization stress-related response (ISRR), occurred more commonly than sARs following both vaccine and placebo and was associated with higher predose anxiety scores, paresthesias, and distinct vital sign and biomarker changes.

CONCLUSIONS

Our findings support revaccination of individuals who report sARs to COVID-19 mRNA vaccines. Distinct clinical and laboratory features may distinguish sARs from ISRRs.

Validation of the NUT CRACKER Diagnostic Algorithm and Prediction for Cashew and Pistachio Co-Allergy

BACKGROUND

Because of the high cross-sensitization among tree nuts, the NUT CRACKER (Nut Co-reactivity-Acquiring Knowledge for Elimination Recommendations) study proposed a diagnostic algorithm to minimize the number of required oral food challenges (OFCs).

OBJECTIVE

To validate the algorithm for cashew and pistachio allergy and determine markers for allergic severity.

METHODS

Patients (n = 125) with a median age of 7.8 (interquartile range, 5.9-11.2) years with suspected tree nut allergy were evaluated prospectively with decision tree points on the basis of skin prick test (SPT), basophil activation test (BAT), and knowledge of the coincidence of allergies. Validation of allergic status was determined by OFC. Markers of clinical severity were evaluated using the combined original and prospective cohort (n = 187) in relationship to SPT, BAT, and Ana o 3-sIgE.

RESULTS

Reactivity to cashew in SPT, BAT, and Ana o 3-sIgE and the incidence of abdominal pain on challenge were significantly higher in dual-allergic cashew/pistachio patients (n = 82) versus single cashew allergic patients (n = 18) (P = .001). All 3 diagnostic tests showed significant inverse correlation with log10 reaction doses for positive cashew OFC. The algorithm reduced overall the total number of OFCs by 72.0%, with a positive predictive value and negative predictive value of 93.0% and 99.0%, respectively. Cashew false-positives were observed primarily in hazelnut-allergic patients (P = .026). In this population, Ana o 3-specific IgE could diagnose cashew allergy with a sensitivity of more than 90% and a specificity of more than 95%.

CONCLUSIONS

The NUT CRACKER diagnostic algorithm was validated and reduced the number of diagnostic OFCs required. Markers for severity phenotypes may guide oral immunotherapy protocols, improving the risk/benefit ratio for patients.

Advancing the allergenicity assessment of new proteins using a text mining resource

With a society increasingly demanding alternative protein food sources, new strategies for evaluating protein safety issues, such as allergenic potential, are needed. Large-scale and systemic studies on allergenic proteins are hindered by the limited and non-harmonized clinical information available for these substances in dedicated databases. A missing key information is that representing the symptomatology of the allergens, especially given in terms of standard vocabularies, that would allow connecting with other biomedical resources to carry out different studies related to human health. In this work, we have generated the first resource with a comprehensive annotation of allergens' symptomatology, using a text-mining approach that extracts significant co-mentions between these entities from the scientific literature (PubMed, ∼36 million abstracts). The method identifies statistically significant co-mentions between the textual descriptions of the two types of entities in the literature as indication of relationship. 1,180 clinical signs extracted from the Human Phenotype Ontology, the Medical Subject Heading terms of PubMed together with other allergen-specific symptoms, were linked to 1,036 unique allergens annotated in two main allergen-related public databases via 14,009 relationships. This novel resource, publicly available through an interactive web interface, could serve as a starting point for future manually curated compilation of allergen symptomatology.

Implementing Food Oral Immunotherapy Into Clinical Practice: Quality and Safety Perspectives From a US Academic Center

Oral immunotherapy (OIT) is an accessible procedure for practicing allergy/immunology providers, yet rigorous safety standards are limited in the clinical setting. By exploring the transition from research to clinical practice OIT, we review relevant safety considerations necessary for the clinical provider. We offer a perspective on clinical benefits and considerations at the individual, collaboration, and policy levels from the vantage of a large academic OIT program, and we propose several practical start-up checklists and clerical considerations for practicing providers. Awareness of the local population and front-end planning is necessary to improve the accessibility of this procedure in clinical practice among racial and socioeconomic minority populations. Sharing and merging OIT protocols, procedural methods, and electronic medical record order sets may increase harmonization among OIT-providing institutions and further our abilities to pool safety and outcomes data, ultimately enhancing the safety and efficacy of clinical OIT.

Beta-lactam antibiotics administration among adult inpatients with a beta-lactam allergy label: incidence, predictors, and outcomes

Background

A beta-lactam antibiotics (BLA) allergy label is common, resulting in disadvantageous outcomes due to the usage of second-line antimicrobial agents. Noncontrolled case-series analyses report low rates of hypersensitivity reactions, following intentional/non-intentional BLA challenges among labeled inpatients. The study aims were to explore predictors and outcomes associated with hypersensitivity reactions following BLA challenge among BLA-allergic labeled inpatients.

Methods

Retrospective cohort study (2019-2020) of adult (≥18 years) inpatients (Shamir Medical Center, Israel), labeled as allergic to ≥1 BLA, who received ≥1 dose/s of BLA during their stay. Independent predictors to develop allergic reactions and the independent associations of allergic reactions with clinical outcomes were queried by logistic and Cox regressions.

Results

Of 9,670 inpatients (14,088 hospitalizations), 3,570 (37%) were labeled as allergic to ≥1 BLA. Of those, 1,171 (33%) patients received ≥1 BLA. The majority were women (67%), and the mean age was 69.3 ± 19.4 years. Only 30 patients (2.6%) developed a reaction, all mild. Independent predictors to develop an allergic reaction were documented reactions in the past, atopic background, antihistamines administration prior to the BLA challenge, and high risk for cross-reactivity, based on the BLA side chains, between the labeled and the challenged agents. Reaction upon the BLA challenge was not independently associated with any worse outcome.

Conclusions

Despite the commonality of allergy labeling, and the commonality of BLA administration to labeled inpatients, hypersensitivity reactions were mild and rare. Interventional stewardship strategies for active BLA de-labeling among low-risk patients should be promoted, to improve patients' and institutional health and fiscal outcomes.

Omalizumab for the Treatment of Multiple Food Allergies

BACKGROUND

Food allergies are common and are associated with substantial morbidity; the only approved treatment is oral immunotherapy for peanut allergy.

METHODS

In this trial, we assessed whether omalizumab, a monoclonal anti-IgE antibody, would be effective and safe as monotherapy in patients with multiple food allergies. Persons 1 to 55 years of age who were allergic to peanuts and at least two other trial-specified foods (cashew, milk, egg, walnut, wheat, and hazelnut) were screened. Inclusion required a reaction to a food challenge of 100 mg or less of peanut protein and 300 mg or less of the two other foods. Participants were randomly assigned, in a 2:1 ratio, to receive omalizumab or placebo administered subcutaneously (with the dose based on weight and IgE levels) every 2 to 4 weeks for 16 to 20 weeks, after which the challenges were repeated. The primary end point was ingestion of peanut protein in a single dose of 600 mg or more without dose-limiting symptoms. The three key secondary end points were the consumption of cashew, of milk, and of egg in single doses of at least 1000 mg each without dose-limiting symptoms. The first 60 participants (59 of whom were children or adolescents) who completed this first stage were enrolled in a 24-week open-label extension.

RESULTS

Of the 462 persons who were screened, 180 underwent randomization. The analysis population consisted of the 177 children and adolescents (1 to 17 years of age). A total of 79 of the 118 participants (67%) receiving omalizumab met the primary end-point criteria, as compared with 4 of the 59 participants (7%) receiving placebo (P<0.001). Results for the key secondary end points were consistent with those of the primary end point (cashew, 41% vs. 3%; milk, 66% vs. 10%; egg, 67% vs. 0%; P<0.001 for all comparisons). Safety end points did not differ between the groups, aside from more injection-site reactions in the omalizumab group.

CONCLUSIONS

In persons as young as 1 year of age with multiple food allergies, omalizumab treatment for 16 weeks was superior to placebo in increasing the reaction threshold for peanut and other common food allergens. (Funded by the National Institute of Allergy and Infectious Diseases and others; ClinicalTrials.gov number, NCT03881696.).

Updated grading system for systemic allergic reactions: Joint Statement of the World Allergy Organization Anaphylaxis Committee and Allergen Immunotherapy Committee

There is a lack of consensus over the description and severity assignment of allergic adverse reactions to immunotherapy, although there seems to be a consensus at least in terms of using the World Allergy Organization (WAO) grading systems to describe local adverse events for Sublingual Immunotherapy (SLIT) and Systemic Allergic Reactions (SARs) to Subcutaneous Immunotherapy (SCIT) amongst the major national/regional allergy societies. In this manuscript, we propose a modification of the previous WAO Grading system for SARs, which aligns with the newly-proposed Consortium for Food Allergy Research (CoFAR) Grading Scale for Systemic Allergic Reactions in Food Allergy (version 3.0). We hope this can facilitate a unified grading system appropriate to SARs due to allergen immunotherapy, independent of allergen and route of administration, and across clinical and research practice.

Feast for thought: A comprehensive review of food allergy 2021-2023

A review of the latest publications in food allergy over the past couple of years confirmed that food allergy is a major public health concern, affecting about 8% of children and 10% of adults in developed countries. The prevalence of food allergy varies around the world, with the increase being driven mainly by environmental factors, possibly together with genetic susceptibility to environmental changes. A precise diagnosis of food allergy is extremely important. Both new tests (eg, the basophil activation test) and improved optimization of information provided by existing tests (eg, the skin prick test and measurement of specific IgE level) can contribute to improving the accuracy and patients' comfort of food allergy diagnosis. Understanding the underlying immune mechanisms is fundamental to designing allergen-specific treatments that can be safe and effective in the long term. New discoveries of the immune response to food allergens, including T-cell and B-cell responses, have emerged. Novel therapeutic approaches are being trialed at various stages of development as attempts to allow for more active intervention to treat food allergy. Prevention is key to reducing the increase in prevalence. Early introduction of allergenic foods seems to be the most effective intervention, but others are being studied, and will, it is hoped, lead to modification of the epidemiologic trajectory of food allergy over time.

Anaphylaxis: A 2023 practice parameter update

This practice parameter update focuses on 7 areas in which there are new evidence and new recommendations. Diagnostic criteria for anaphylaxis have been revised, and patterns of anaphylaxis are defined. Measurement of serum tryptase is important for diagnosis of anaphylaxis and to identify underlying mast cell disorders. In infants and toddlers, age-specific symptoms may differ from older children and adults, patient age is not correlated with reaction severity, and anaphylaxis is unlikely to be the initial reaction to an allergen on first exposure. Different community settings for anaphylaxis require specific measures for prevention and treatment of anaphylaxis. Optimal prescribing and use of epinephrine autoinjector devices require specific counseling and training of patients and caregivers, including when and how to administer the epinephrine autoinjector and whether and when to call 911. If epinephrine is used promptly, immediate activation of emergency medical services may not be required if the patient experiences a prompt, complete, and durable response. For most medical indications, the risk of stopping or changing beta-blocker or angiotensin-converting enzyme inhibitor medication may exceed the risk of more severe anaphylaxis if the medication is continued, especially in patients with insect sting anaphylaxis. Evaluation for mastocytosis, including a bone marrow biopsy, should be considered for adult patients with severe insect sting anaphylaxis or recurrent idiopathic anaphylaxis. After perioperative anaphylaxis, repeat anesthesia may proceed in the context of shared decision-making and based on the history and results of diagnostic evaluation with skin tests or in vitro tests when available, and supervised challenge when necessary.

United States Drug Allergy Registry (USDAR) grading scale for immediate drug reactions

BACKGROUND

There is no accepted grading system classifying the severity of immediate reactions to drugs.

OBJECTIVE

The purpose of this article is to present a proposed grading system developed through the consensus of drug allergy experts from the United States Drug Allergy Registry (USDAR) Consortium.

METHODS

The USDAR investigators sought to develop a consensus severity grading system for immediate drug reactions that is applicable to clinical care and research.

RESULTS

The USDAR grading scale scores severity levels on a scale of 0 to 4. A grade of no reaction (NR) is used for patients who undergo challenge without any symptoms or signs, and it would confirm a negative challenge result. A grade 0 reaction is indicative of primarily subjective complaints that are commonly seen with both historical drug reactions and during drug challenges, and it would suggest a low likelihood of a true drug allergic reaction. Grades 1 to 4 meet the criteria for a positive challenge result and may be considered indicative of a drug allergy. Grade 1 reactions are suggestive of a potential immediate drug reaction with mild symptoms. Grade 2 reactions are more likely to be immediate drug reactions of moderate severity. Grade 3 reactions have features suggestive of a severe allergic reaction, whereas grade 4 reactions are life-threatening reactions such as anaphylactic shock and fatal anaphylaxis.

CONCLUSION

This proposed grading schema for immediate drug reactions improves on prior schemata by being developed specifically for immediate drug reactions and being easy to implement in clinical and research practice.

Sesame eliciting and safe doses in a large sesame allergic population

BACKGROUND

Sesame is a significant food allergen causing severe and even fatal reactions. Given its increasing prevalence in western diet, sesame is listed as an allergenic food requiring labeling in the United States and EU. However, data on the population reaction doses to sesame are limited.

METHODS

All sesame oral food challenges (OFCs), performed either for diagnosis or for threshold identification before the beginning of sesame oral immunotherapy (OIT) between November 2011 and July 2021 in Shamir medical center were analyzed for reaction threshold distribution. Safe-dose challenges with 90-120 min intervals were also analyzed.

RESULTS

Two hundred and fifty patients underwent 338 positive OFCs, and additional 158 safe-dose OFCs were performed. The discrete and cumulative protein amounts estimated to elicit an objective reaction in 1% (ED01) of the entire cohort (n = 250) were 0.8 mg (range 0.3-6.3) and 0.7 mg (range 0.1-7.1), respectively, and those for 5% of the population (ED05) were 3.4 mg (range 1.2-20.6) and 4.5 mg (range 1.2-28.8), respectively. Safe-dose OFCs showed similar values of ED01 (0.8, 0.4-7.5 mg) and ED05 (3.4, 1.2-22.9 mg). While doses of ≤1 mg sesame protein elicited oral pruritus in 11.6% of the patients, no objective reaction was documented to this amount in any of the challenges, including safe-dose OFCs.

CONCLUSIONS

This study provides data on sesame reaction threshold distribution in the largest population of allergic patients studied, with no right or left censored data, and with validation using a safe-dose OFC. It further supports the current methods for ED determination as appropriate for establishing safety precautions for the food industry.

Living with food allergies: the experiences of adult patients and caregivers

Background

Few studies have addressed how food allergy may impact differently on the daily lives of adults with food allergies and caregivers for food-allergic dependents.

Objective

To explore similarities and differences in life experiences and unmet needs between individuals caring for a child with food allergy and adults with food allergy world-wide.

Methods

Two multinational, virtual, interactive, moderated discussions of specific questions between respectively people with food allergies and caregivers for people with food allergies, with experienced clinicians participating.

Results

Sixteen individuals living with food allergies and nine caregivers took part in the two roundtables. Food avoidance and antihistamines were the most common treatments for food-allergic reactions in both groups. Caregivers reported greater burden of disease on affected individuals and families than did adult patients. Adult panelists considered autoinjectors easy to use but caregivers reported additional emotional stress thinking about autoinjector use. Caregivers described an ever-present fear of inattention and of overlooking a risk factor for a severe reaction, whereas adult panelists showed a determination not to let their food allergies interfere with living their lives. Both groups had safety-conscious attitudes to treatments, but adult patients emphasized convenience while caregivers prioritized reduced severity of reactions and eliminated fear. Both groups confirmed the need for improved, trusted sources of information, and for resources and training programs for any new therapies.

Conclusion

The interactive exchange provided insights into differences between adult patients and caregivers, notably in fear and confidence in daily life, severity of disease impact, and unmet needs for treatments.

Severe Anaphylactic Reactions to Home Doses of Oral Immunotherapy for Food Allergy

BACKGROUND

Severe anaphylactic reactions to home doses may occur during food allergy oral immunotherapy (OIT).

OBJECTIVE

To study the rate and risk factors for such reactions.

METHODS

We studied all patients aged greater than 3.5 years who completed OIT in a single center between April 2010 and January 2020. All home epinephrine-treated reactions (HETRs) were identified. High-grade HETRs (HG-HETRs) were defined as HETRs involving respiratory (SpO2 of 94% or less), cardiovascular (low blood pressure), or central nervous system impairment (loss of consciousness). We investigated the rate and risk factors for HG-HETRs.

RESULTS

A total of 1,637 OIT treatments were studied: milk (880), peanut (346), tree nuts (221), sesame (115), and egg (75). Of 390 identified HETRs, 30 HG-HETRs occurred during 27 treatments (1.65% of all treatments). Nearly all (26 of 30) were during milk OIT in patients with house dust mite (HDM) sensitization and asthma (26 of 30 each). Of the 30 patients with HG-HETRs, 21 recovered with one or two epinephrine treatments, but nine (0.55% of all treatments) did not respond to a second dose of epinephrine and were deemed to have refractory anaphylaxis. Three patients required intensive care unit admission and three received epinephrine drip, but none required ventilatory support. Risk factors for HG-HETRs included milk OIT (P = .031), asthma (P = .02) and HDM sensitization (P = .02). No specific triggers for HG-HETR were identified. Of patients with HG-HETRs, 25.9% were fully desensitized, including the four non-milk treated patients; 22.2% were partially desensitized; and 51.9% failed.

CONCLUSIONS

High-grade HETRs are uncommon, particularly refractory anaphylactic reactions to home OIT doses. Although milk OIT, asthma, and HDM sensitization are the main risk factors for such reactions, identification of patients who are at risk is challenging.

How to define severity: A review of allergic reaction severity scoring systems

Numerous scoring systems have been developed to improve and standardize the diagnosis and management of acute allergic reactions and anaphylaxis; however, considerable variability exists among these systems. This review article discusses existing severity scoring systems and identifies specific knowledge gaps that remain. Future research is needed to resolve the limitations of existing grading systems, including attempting to link reaction severity with treatment advice and conducting validation studies in different clinical settings, patient populations, and geographies to promote grading system application and dissemination in both clinical care and research.

Refractory Anaphylaxis: A New Entity for Severe Anaphylaxis

Anaphylaxis reactions lie on a spectrum of severity, ranging from relatively mild lower respiratory involvement (depending on the definition of anaphylaxis used) to more severe reactions that are refractory to initial treatment with epinephrine and may rarely cause death. A variety of grading scales exist to characterize severe reactions, but there is a lack of consensus about the optimal approach to define severity. More recently, a new entity called refractory anaphylaxis (RA) has emerged in the literature, characterized by the persistence of anaphylaxis despite initial epinephrine treatment. However, slightly different definitions have been proposed to date. In this Rostrum, we review these definitions as well as data relating to epidemiology, elicitors, risk factors, and management of RA. We propose a need to align the different definitions for RA, to improve epidemiological surveillance, advance our understanding of the pathophysiology of RA, and optimize management strategies to reduce morbidity and mortality.

Impact of using less objective symptoms to define tolerated dose during food challenges: A data-driven approach

BACKGROUND

Food challenges (FCs) form the basis for assessing efficacy outcomes in interventional studies of food allergy; however, different studies have used a variety of similar but not identical criteria to define a challenge reaction, including subjective (nonobjective) symptoms occurring in a single-organ system as dose limiting.

OBJECTIVE

Our aim was to undertake a secondary analysis of 4 interventional studies to assess the impact of using less objective criteria to determine challenge-stop on reaction thresholds and their reproducibility.

METHODS

We analyzed individual participant data, including individual participant data meta-analysis, by using 3 different published challenge-stop criteria: (1) PRACTALL consesus criteria; (2) Consortium for Food Allergy Research version 3 (CoFAR v3) with at least 1 moderate- or severe-grade symptom; or (3) CoFAR v3 with at least 2 mild symptoms occurring in different organ systems. Reproducibility of challenge threshold was also assessed in participants undergoing subsequent repeat FCs.

RESULTS

Four studies, with detailed challenge data from a total of 592 participants, were included. Applying CoFAR v3 definitions for dose-limiting symptoms resulted in an underestimate of reaction thresholds compared with those in PRACTALL (P < .001) that is equivalent to almost a single dosing increment when using a semi-log dosing regimen. Reproducibility was also reduced when applying CoFAR v3 (P < .001 [n = 223]). Using the least conservative interpretation of CoFAR v3 (≥2 mild symptoms occurring in different systems) resulted in a significant overestimate of 15% when assessing oral immunotherapy efficacy. Applying a data-driven minor modification to CoFAR v3 resulted in a new set of challenge-stop criteria with validity similar to that of PRACTALL but one that is simpler to implement and in which significant gastrointestinal discomfort with observable decreased activity remains a dose-limiting symptom.

CONCLUSION

The use of less objective symptoms to define challenge-stop compromises the reproducibility of the FC as a tool to assess efficacy outcomes in interventional studies, and potentially overestimates the efficacy of the intervention tested.

Abatacept to induce remission of peanut allergy during oral immunotherapy (ATARI): protocol for a phase 2a randomized controlled trial

Context

While oral immunotherapy (OIT) has been shown to promote the remission of mild peanut allergy in young children, there is still an unmet need for a disease-modifying intervention for older patients and those with severe diseases. In mice models, abatacept, a cytotoxic T lymphocyte-associated antigen-4 (CTLA-4) immunoglobulin fusion protein, has been shown to promote immune tolerance to food when used as an adjuvant to allergen immunotherapy. The goal of this study is to explore the potential efficacy of abatacept in promoting immune tolerance to food allergens during OIT in humans.

Methods

In this phase 2a proof-of-concept study (NCT04872218), 14 peanut-allergic participants aged from 14 to 55 years will be randomized at a 1:1 ratio to abatacept vs. placebo for the first 24 weeks of a peanut OIT treatment (target maintenance dose of 300 mg peanut protein). The primary outcome will be the suppression of the OIT-induced surge in peanut-specific IgE/total IgE at 24 weeks, relative to the baseline. Sustained unresponsiveness will be assessed as a secondary outcome starting at 36 weeks by observing incremental periods of peanut avoidance followed by oral food challenges.

Discussion

This is the first study assessing the use of abatacept as an adjuvant to allergen immunotherapy in humans. As observed in preclinical studies, the ability of abatacept to modulate the peanut-specific immune response during OIT will serve as a proxy outcome for the development of clinical tolerance, given the small sample size. The study will also test a new patient-oriented approach to sustained tolerance testing in randomized controlled trials.

Grading the severity of anaphylaxis

PURPOSE OF REVIEW

Despite no global consensus on a definition of anaphylaxis, there is increasing recognition that just as allergic reactions lie on a spectrum of severity, the same is for anaphylaxis. A variety of severity scores exist in the literature. We review the approaches taken to develop these scores, and their relative advantages and disadvantages.

RECENT FINDINGS

There have been four recent comparisons of published severity scores. All have highlighted the heterogeneity between scoring systems, and the lack of transferability from one approach to another. Notably, only one score has been developed using a data-driven approach, and none has undergone formal and comprehensive validation.

SUMMARY

It is unclear whether a single severity score is achievable, or indeed desirable. If the aim is to guide management of acute reactions, then assignment of severity is not only unnecessary but might delay treatment and cause harm. Severity scores are needed in the research setting, but require an approach which can discriminate between reactions of similar but nonidentical severity (particularly, nonanaphylaxis reactions). Any approach should be fit for purpose, informed by patient and clinician experience, and ideally be data-driven to minimize subjective bias and facilitate objective validation.

Clinical outcomes of efficacy in food allergen immunotherapy trials

PURPOSE OF REVIEW

With food allergy affecting millions of children worldwide, the consolidation of food allergen immunotherapy represents an encouraging therapeutic option, that might expand in the next few years to reach greater number of candidates. This review aims at providing a critical overview of the efficacy outcomes employed in food allergen immunotherapy trials (AIT).

RECENT FINDINGS

Understanding efficacy endpoints rely on identifying what and how these are being measured. Desensitization, as the efficacy of the therapy to increase the patient's reactivity threshold to the food during therapy, and Sustained Unresponsiveness, withholding such efficacy even if the therapy is withdrawn, are nowadays considered the main parameters of efficacy evaluation. Quality of life is a promising variable to capture food AIT impact from the patient's perspective.There is a relevant degree of heterogeneity across studies in outcomes definitions and also in oral food challenges design, the tool that is more spread to assess results, hampering study comparison.

SUMMARY

Interpreting the results of a clinical trial, and comparing data from different studies is an important task, both for the researcher and the clinician, that should be done after a careful analysis of the outcomes and the evaluation tools used.

Food allergy risks and dining industry – an assessment and a path forward

Food allergies have increased in prevalence over the last few decades and continue to grow. Consumption of even trace amounts of common foods can cause a rapid allergic reaction (generally within minutes) which can be mild to severe to even life-threatening. Eating at restaurants poses a risk of allergic reactions for those with food allergies due to inadequate, inconsistent labeling of allergens in foods. Here, we review food labeling rules and practices in the restaurant industry and compare and contrast it with food labeling for prepackaged foods. We review global and United States trends, and provide a brief historical overview. The paper describes the key legal and economic motivations behind restaurant food labeling. Next, we describe novel risk-driven policies and new biotechnologies that have the potential to change food labeling practices worldwide. Finally, we outline desirable federal regulations and voluntary information disclosures that would positively impact the public health aspects of restaurant food labeling and improve the quality of life for people with severe food allergies.

WAO consensus on DEfinition of Food Allergy SEverity (DEFASE)

Background

While several scoring systems for the severity of anaphylactic reactions have been developed, there is a lack of consensus on definition and categorisation of severity of food allergy disease as a whole.

Aim

To develop an international consensus on the severity of food allergy (DEfinition of Food Allergy Severity, DEFASE) scoring system, to be used globally.

Methods Phase 1

We conducted a mixed-method systematic review (SR) of 11 databases for published and unpublished literature on severity of food allergy management and set up a panel of international experts.

Phase 2

Based on our findings in Phase 1, we drafted statements for a two-round modified electronic Delphi (e-Delphi) survey. A purposefully selected multidisciplinary international expert panel on food allergy (n = 60) was identified and sent a structured questionnaire, including a set of statements on different domains of food allergy severity related to symptoms, health-related quality of life, and economic impact. Participants were asked to score their agreement on each statement on a 5-point Likert scale ranging from "strongly agree" to "strongly disagree". Median scores and percentage agreements were calculated. Consensus was defined a priori as being achieved if 70% or more of panel members rated a statement as "strongly agree" to "agree" after the second round. Based on feedback, 2 additional online voting rounds were conducted.

Results

We received responses from 92% of Delphi panel members in round 1 and 85% in round 2. Consensus was achieved on the overall score and in all of the 5 specific key domains as essential components of the DEFASE score.

Conclusions

The DEFASE score is the first comprehensive grading of food allergy severity that considers not only the severity of a single reaction, but the whole disease spectrum. An international consensus has been achieved regarding a scoring system for food allergy disease. It offers an evaluation grid, which may help to rate the severity of food allergy. Phase 3 will involve validating the scoring system in research settings, and implementing it in clinical practice.

Endpoints and Outcomes After Immunotherapy for Food Allergy: What Is Meaningful for Patients?

Multiple novel interventions for food allergy are currently at various stages of development with the goal of reducing or eliminating allergic reactions. However, the relative success of these therapeutics in achieving meaningful, long-term improvements to patients' lives is difficult to determine as there is currently very limited understanding of the degree of alignment between clinical trial efficacy endpoints and patient-centered outcomes. Furthermore, outcome measures used in clinical trials of food allergy immunotherapies vary widely, are often misinterpreted, and not necessarily consistent with what patients expect to achieve through treatment. This review aims to assist clinicians in critically interpreting outcomes reported in clinical trials and accurately communicating risks and outcomes to patients when practicing shared decision-making.

Treatment for food allergy: Current status and unmet needs

The treatment of food allergy has traditionally relied on avoidance of the offending food(s) and use of emergency medications in the event of accidental exposures. However, this long-standing paradigm is beginning to shift, as a variety of treatment approaches have been and are being developed. This report provides an overview of the past, present, and future landscape of interventional clinical trials for the treatment of food allergy. It focuses on specific issues related to participant characteristics, protocol design, and study end points in the key clinical trials in the literature and examine how differences between studies may impact the clinical significance of the study results. Recommendations are provided for the optimization of future trial designs and focus on specific unmet needs in this rapidly evolving field.

Management of Anaphylaxis During Peanut Oral Immunotherapy

BACKGROUND

Peanut oral immunotherapy (POIT) has emerged as an active management option for peanut allergy, with an FDA-approved product now available for therapy. Allergic reactions, including anaphylaxis, can occur during therapy and their management is key in optimizing this treatment and patient outcomes.

PURPOSE OF REVIEW

In this manuscript, we will review the rates of allergic reactions and anaphylaxis in seminal peanut oral immunotherapy research studies. We will examine factors that can alter the risk of anaphylaxis and describe various strategies, including adjunct therapies, that have the potential to mitigate anaphylaxis risk based on published evidence.

RECENT FINDINGS

Rates of anaphylaxis and epinephrine administration vary in different research studies, but there is consensus that most POIT-related allergic reactions are mild or moderate and not severe. Certain external factors (for example, tiredness, exercise, viral illness) as well as uncontrolled allergic co-morbidities (asthma, allergic rhinitis) have been shown to increase the risk of anaphylaxis during OIT. The search of biomarkers who may predict who is at risk for severe allergic reactions is ongoing. Adjunct therapies have shown promise, but further studies are required to optimize their use alongside POIT. Our understanding of anaphylaxis during POIT has increased in recent years, resulting in better management strategies. However, future plans will need to involve all stakeholders, including physicians, patients and families, researchers, public health authorities, and the food, hospitality, and catering industries.

Treatment of primary eosinophilic colitis using immunoglobulin/histamine complex

Primary eosinophilic colitis (PEC) is a primary eosinophilic gastrointestinal disorder, and immunoglobulin/histamine complex (IHC) may be an effective therapeutic for PEC. IHC has a nonallergen-specific antinociceptive effect in the treatment of histamine-mediated pain.

Food allergy, mechanisms, diagnosis and treatment: Innovation through a multi-targeted approach

The incidence of food allergy (FA) has continued to rise over the last several decades, posing significant burdens on health and quality of life. Significant strides into the advancement of FA diagnosis, prevention, and treatment have been made in recent years. In an effort to lower reliance on resource-intensive food challenges, the field has continued work toward the development of highly sensitive and specific assays capable of high-throughput analysis to assist in the diagnosis FA. In looking toward early infancy as a critical period in the development of allergy or acquisition of tolerance, evidence has increasingly suggested that early intervention via the early introduction of food allergens and maintenance of skin barrier function may decrease the risk of FA. As such, large-scale investigations are underway evaluating infant feeding and the impact of emollient and steroid use in infants with dry skin for the prevention of allergy. On the other end of the spectrum, the past few years have been witness to an explosive increase in clinical trials of novel and innovative therapeutic strategies aimed at the treatment of FA in those whom the disease has already manifested. A milestone in the field, 2020 marked the approval of the first drug, oral peanut allergen, for the indication of peanut allergy. With a foundation of promising data supporting the safety and efficacy of single- and multi-allergen oral immunotherapy, current efforts have turned toward the use of probiotics, biologic agents, and modified allergens to optimize and improve upon existing paradigms. Through these advancements, the field hopes to gain footing in the ongoing battle against FA.

Guided Gradual Egg-Tolerance Induction in Hen's Egg Allergic Children Tolerating Baked Egg: A Prospective Randomized Trial

Background

Over the last few years, studies have shown that the majority of egg allergic children tolerate baked egg (e.g., cake), and that consuming baked egg accelerates the resolution of egg allergy. However, few prospective studies demonstrate the step-wise reintroduction of egg at home after developing baked egg tolerance. Although this could have a positive impact on the children's quality of life and nutrition. Additionally, research supporting the theoretical concept that heating in the presence or absence of wheat causes reduced allergenicity of egg proteins is limited.

Objective

To investigate the clinically most favorable duration of gradual egg-tolerance induction in baked egg tolerant children at home, with regard to complete raw egg tolerance.

Methods

Baked egg tolerant children above 12 months of age were randomly assigned to a short- or long arm protocol. In the short arm, egg-tolerance induction was studied over 18 months compared to 30 months in the long arm. Children were guided through this protocol involving the step-wise introduction of increasingly allergenic forms of egg starting with baked egg offered as cake, followed by hard-boiled egg, omelet/waffle/pancake, soft-boiled egg, and finally raw egg. We hereby designed this protocol based on the influence of thermal processing in the presence or absence of wheat on egg proteins, as investigated by ELISA, SDS-PAGE, and immunoblotting. At inclusion, children either passed an in-hospital cake challenge or had ovomucoid sIgE ≤1.2 kUA/L, which was considered safe for introduction at home.

Results

Gel electrophoresis revealed that the ovalbumin band became weaker with heating, while the ovomucoid band remained stable. In accordance, the IgE-binding to ovalbumin decreased with extensive heating, as opposed to ovomucoid. However, heating in the presence of wheat led to a decreased IgE reactivity to ovomucoid. Of the 78 children in the intention-to-treat group, 39 were randomized to each arm. Fifty-eight children reached the raw egg tolerance endpoint, of which 80% were in the short arm and 69% in the long arm. Within the short arm, the median time to raw egg tolerance was 24 months (95% CI, 21–27 months) compared to 30 months (95% CI, 28–32 months) in the long arm (p = 0.005). No grade IV reactions or cases of eosinophilic esophagitis were observed. The short arm was considered to be non-inferior to the long arm.

Conclusion

Our gradual short arm protocol appears to be safe and allows clinicians to guide baked egg tolerant children toward raw egg tolerance at home. The allergenicity of the egg proteins was affected by heating temperature and duration, as well as the presence of wheat.