Omalizumab in IgE-Mediated Food Allergy: A Systematic Review and Meta-Analysis

Effect of oral food challenge on quality of life and family activities in children with IgE-mediated food allergies

BACKGROUND

Oral food challenge (OFC) is an integral part of confirming and evaluating the diagnosis of food allergy (FA), and most incidents of FA occur in children. FA significantly impairs the quality of life (QoL) and causes limited activities outside the home for children and their parents.

AIM

To evaluate the effect of OFC on QoL and family activities in children with FA.

METHODS

This prospective study identified children suspected of FA using a skin prick test (SPT) between January 2022 and December 2024. These children conduct an elimination diet for 4 wk, followed by OFC under protocol. Rating scales evaluated QoL using pediatric QoL inventory and family activities using family activities impact scale (FAIS), in which data are collected before and after an elimination diet and OFC. Statistical analysis utilized χ², Spearman , paired t, Wilcoxon, independent t, and Mann–Whitney tests, with P < 0.05 considered significant.

RESULTS

Most participants were boys (137; 65.55%); 102 (64.56%) had a positive OFC and 35 (68.63%) a negative OFC. The average QoL before OFC was 69.13 ± 5.78, and 92.40 ± 4.22 after OFC (Z = 12.537; P < 0.001). In the FAIS score, the average result before OFC was 5.36 ± 0.68 and 4.10 ± 0.38 after OFC, which was a significant difference (Z = 12.162; P < 0.001). Although the difference in QoL before and after increased, and FAIS reduced, there was no significant difference. Additionally, most results of positive SPT are higher than positive OFC in each specific food allergen.

CONCLUSION

OFC may improve QoL and FAIS in children with FA and their families as it increases activities outside the home and reduces worry about allergen exposure.

Standardizing outcomes in food allergy research: aligning clinical trials with patient priorities

PURPOSE OF REVIEW

This review explores the clinical outcomes used in immunoglobulin E (IgE)-mediated food allergy (FA) intervention studies, emphasizing unmet need for patient-centred outcomes. Standardizing outcome measurement is critical as research into FA treatments, particularly food immunotherapy, expands. Here we discuss how outcomes should reflect the multidimensional impact of FA on people's lives.

RECENT FINDINGS

Current evidence reveals a discrepancy between clinical trial outcomes and those most valued by patients and carers. While trials often prioritize changes in reactivity thresholds or immunological markers, patients and carers emphasize need in reducing severe reactions, improving quality of life, and enhancing confidence in disease management. This disparity highlights importance of harmonization efforts to guide FA research.The Core Outcome Measures for Food Allergy (COMFA) initiative recently identified two core outcomes - 'allergic symptoms' and 'quality of life' - through an international consensus process involving patients, caregivers, clinicians, and researchers. Outcomes like 'desensitization' and 'remission/sustained unresponsiveness' were considered important but were not seen as the most critical.

SUMMARY

Developing and implementing a COS for FA intervention studies is essential to align research with patient priorities, ensuring meaningful improvements in routine clinical care. Standardized outcome measurement will generate robust evidence, inform clinical practice, and empower patients and caregivers in decision-making about FA management.

Omalizumab is ineffective in regulating proasthmatic serum cytokine and chemokine levels in nonresponders with high BMI

Background

Omalizumab provides clinical benefits to a fraction of patients with asthma. It remains unclear why some patients do not respond to omalizumab therapy.

Objective

We sought to investigate whether omalizumab could alter serum cytokine and chemokine levels that could be associated with asthma pathogenesis. We also investigated why omalizumab is ineffective in controlling proasthmatic serum cytokine and chemokine levels in nonresponders.

Methods

Serum cytokine and chemokine levels in patients with moderate to severe asthma (N = 45; 34 responders and 11 nonresponders) were assessed before and after 26 weeks of omalizumab therapy. Correlations between cytokine and chemokine levels and asthma symptoms as well as characteristics of responders and nonresponders were assessed. Nonasthmatic subjects (N = 22) served as controls for patients with asthma (N = 45).

Results

Omalizumab was more effective in patients with increased serum eotaxin-1 and IL-13 levels than in others at baseline. Omalizumab decreased eotaxin-1 and IL-13, along with levels of most of the cytokines and chemokines tested, including IL-7, CCL17, and CXCL10, in responders, except for CCL5 and CCL22, which can contribute to neutrophilic and type 2 airway inflammation, respectively. In contrast, omalizumab did not decrease such serum cytokine and chemokine levels in nonresponders. Of interest, serum CCL17, CCL22, CXCL10, and IL-7 levels in nonresponders were associated with their body mass index, which could explain why omalizumab was unable to reduce their concentrations in nonresponders.

Conclusions

Omalizumab can regulate most cytokine and chemokine levels in responders. However, in nonresponders, it is unable to modulate specific proasthmatic cytokines and chemokines due to their association with individual body mass index, which is not influenced by omalizumab.

Long-Term Safety of Epicutaneous Immunotherapy in Peanut-Allergic Children: An Open-Label Active Treatment (REALISE Study)

BACKGROUND

Owing to limited treatment options for peanut allergy, patients remain at risk for allergic reactions due to accidental exposure. Epicutaneous immunotherapy (EPIT) is a novel treatment being investigated for peanut allergy.

OBJECTIVE

This study assessed long-term safety of EPIT with VIASKIN peanut patch 250 μg (VP250) via an open-label extension of the REAL Life Use and Safety of EPIT (REALISE) trial.

METHODS

REALISE was a phase 3 trial in peanut-allergic children aged 4 through 11 years that included a 6-month, randomized, double-blind, placebo-controlled treatment phase, followed by an open-label, single-arm, active treatment period for up to 36 months.

RESULTS

Of the 392 participants (male 54.8%; median age 7.2 y) who received at least 1 dose of treatment, 77.8% completed the 36-month active treatment. Mean adherence to treatment was high at 96.4%. Most participants (98.7%) experienced at least 1 treatment-emergent adverse event (TEAE); the majority were mild or moderate and decreased in frequency and severity over time. Most participants (94.6%) experienced at least 1 treatment-related TEAE. Local skin reactions were the most common treatment-related TEAE with the incidence decreasing from year 1 (87.8%) to year 3 (19.2%). Serious treatment-related TEAEs were reported in 2 participants. No specific safety signals were identified in the 14 participants enrolled with a history of severe anaphylaxis (Anaphylaxis Staging System grade 3).

CONCLUSION

Consistent with previous phase 3 studies, long-term EPIT with VIASKIN peanut patch 250 μg was well tolerated with high adherence in peanut-allergic children aged 4 through 11 years (clinicaltrials.gov; NCT: NCT02916446).

Immune therapies in coeliac disease and food allergies: Advances, challenges, and opportunities

Coeliac disease and food allergy management primarily relies on the strict avoidance of dietary antigens. This approach is challenging to maintain in real-world settings and in food allergy carries the risk of life-threatening anaphylaxis. Despite their distinct pathogenesis, both disorders are driven by maladaptive responses to dietary proteins, creating opportunities for shared treatment strategies. In food allergy, desensitisation therapies such as oral, sublingual, and epicutaneous immunotherapy are well-established, complemented by biologics like omalizumab and dupilumab. However, the induction of sustained tolerance remains challenging. In contrast, therapeutic advancements for coeliac disease are still in their early stages. Current efforts focus on gluten detoxification or modification, immune blockade or modulation, tolerogenic approaches, and barrier restoration. Emerging therapies, including JAK and BTK inhibitors and microbiome-targeted interventions, support further targeted treatment options for both conditions. Biomarkers tracking gluten-specific T cells have emerged as valuable tools for immunomonitoring and symptom assessment in coeliac disease, although standardisation of patient-reported outcome measures and gluten challenge protocols is still needed. Food allergy trials are reliant on double-blind placebo-controlled food challenges to measure allergen reactivity, but these are time-consuming, carry risks, and underscore the need for surrogate biomarkers. The successful development of immune-targeted therapies will require building an immune toolset to optimally assess systemic responses to antigens in both conditions. Clinically, this could lead to better outcomes for patients who might otherwise remain undiagnosed or untreated due to the absence of significant enteropathy or allergen-specific symptoms.

Scientific developments in understanding food allergy prevention, diagnosis, and treatment

Food allergies (FAs) are adverse immune reactions to normally innocuous foods. Their prevalence has been increasing in recent decades. They can be IgE-mediated, non-IgE mediated, or mixed. Of these, the mechanisms underlying IgE-mediated FA are the best understood and this has assisted in the development of therapeutics. Currently there are two approved drugs for the treatment of FA, Palforzia and Omalizumab. Palfornia is a characterized peanut product used as immunotherapy for peanut allergy. Immunotherapy, involves exposure of the patient to small but increasing doses of the allergen and slowly builds immune tolerance to the allergen and increases a patient's allergic threshold. Omalizumab, a biologic, is an anti-IgE antibody which binds to IgE and prevents release of proinflammatory allergenic mediators on exposure to allergen. Other biologics, investigational vaccines, nanoparticles, Janus Kinase and Bruton's tyrosine kinase inhibitors, or DARPins are also being evaluated as potential therapeutics. Oral food challenges (OFC) are the gold standard for the diagnosis for FA. However, they are time-consuming and involve risk of anaphylaxis; therefore, alternative diagnostic methods are being evaluated. This review will discuss how the immune system mediates an allergic response to specific foods, as well as FA risk factors, diagnosis, prevention, and treatments for FA.

Omalizumab in Food Allergy in Children: Current Evidence and Future Perspectives

Omalizumab (OMA) is gaining recognition as a promising therapeutic approach for IgE-mediated food allergies in pediatric patients. We conducted a review analyzing 22 studies, including randomized controlled trials, observational studies, and case reports, to evaluate the efficacy and safety of OMA in food allergy management in children and adolescents. The results indicate that OMA, whether used as monotherapy or in combination with oral immunotherapy (OIT), significantly increases allergen tolerance, reduces the severity of allergic reactions, and improves patients' quality of life. When used alongside OIT, OMA reduced adverse reactions during dose escalation and maintenance phases, facilitating safer and more effective desensitization. Additionally, OMA demonstrated benefits beyond food allergy management, including improved asthma control and a reduction in food allergy-related anxiety. However, challenges remain, including high costs, the need for standardized treatment protocols, and limitations related to total IgE thresholds for eligibility. While OMA has been FDA-approved for food allergy treatment in the United States, further research is needed to establish long-term efficacy, optimal dosing strategies, and its role in sustained tolerance development. Future research should focus on optimizing treatment protocols and identifying which patients will benefit the most. Integrating omalizumab into food allergy management could revolutionize pediatric care, offering hope for a safer, more effective approach to desensitization.

Omalizumab reduces anaphylactic reactions and allows food introduction in food-allergic in children with severe asthma: An observational study

BACKGROUND

In Europe, Omalizumab (anti-IgE) is indicated for the treatment of moderate to severe asthma, but not for IgE-mediated food allergy (FA).

OBJECTIVE

We assessed the impact of Omalizumab on efficacy, safety, and quality of life (FA-QoL) in patients with moderate to severe asthma and who have a history of anaphylaxis to peanut, tree nuts, fish, egg, milk, and/or wheat.

METHODS

Food-allergic children (6-18 years) with moderate to severe asthma underwent oral food challenges (OFCs) to establish the threshold of reaction to the culprit food(s) at baseline (T0) and at 4-month intervals (T1, T2, and T3) during their first year of treatment with Omalizumab. We recorded the number and severity of food-allergic reactions, Asthma Control Test (ACT) scores, FA-QoL, and total IgE levels.

RESULTS

In 65 patients allergic to 107 foods, the No Observed Adverse Events Level (NOAEL) at T1 increased: 243- and 488-fold for fresh and baked milk, respectively; 172- and 134-fold for raw and baked egg; 245-fold for hazelnut; 55-fold for peanut; 31-fold for wheat; and 10-fold for fish. Full tolerance was achieved in 66.4% of OFCs at T1, 58.3% at T2, and 75% at T3. Ninety-five foods were liberalized in the diet of 55 patients; the remaining 12 were introduced by 10 patients at least in traces. Throughout the study, 40 out of 65 were able to get a free diet. ACT increased from 17 (Q1-Q3: 15-17) to 23.6 (Q1-Q3: 23-25). The FA-QoL score in children ≤12 years decreased from 4.63 ± 0.74 to 2.02 ± 1.13, and in adolescents from 4.68 ± 0.92 to 1.90 ± 1.50.

CONCLUSIONS

During Omalizumab therapy, a safe reintroduction of allergenic foods is feasible.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT06316414.

Efficacy of omalizumab in food allergic adults - A retrospective analysis

Background

IgE-mediated food allergy poses a significant public health concern, currently with no approved therapies for adults in Europe. Omalizumab (OMA) used as monotherapy or in conjunction with oral immunotherapy (OIT) has been suggested as an efficacious treatment for severe food allergy. The aim of this study was to analyze real-world data from food-allergic patients treated with OMA.

Methods

We included food-allergic patients treated with OMA between 2002 and 2022 throughout Europe. Treatment responders (TR) were identified based on the unresponsiveness to related food allergens (determined by food challenge), reduction in the severity of food allergy and absence of anaphylactic reactions.

Results

Sixty-two patients (female n = 39/62, 62.9%; mean age 30.6 years) were included into this analysis, most of whom were polysensitized to more than 2 food allergens (n = 40/62, 64.5%); 45/62 patients (72.6%) received OMA in conjunction with OIT, while the remaining patients underwent OMA monotherapy. The eliciting food allergens were tree nuts (n = 27/62, 43.5%), cow's milk (n = 26/62, 41.9%), and vegetables (n = 25/62, 40.3%). In most cases, OMA was initiated with 300 mg q4w (n = 51/62, 82.3%) dosing. Treatment was tolerated exceptionally well.Fifty-two (52/62) patients (83.9%) were classified as treatment responders. Six (6/62) patients (9.7%) developed unresponsiveness, 6/62 (9.7%) had a reduction of the severity of food allergy, and 40/62 (64.5%) had no further anaphylactic reactions during treatment. One (1/62) patient (1.6%) undergoing monotherapy was a non-responder, exhibiting repeated anaphylactic reactions to accidental exposures, and 10/62 patients (16.1%) reported anaphylactic reactions during treatment. In most of these cases, cofactors (n = 5/10, 50%) were present.

Conclusion

Our real-world evidence data indicate efficacy and tolerability of OMA for the treatment of IgE-mediated food allergy with and without OIT. As the onset of food related reactions upon treatment was frequently linked to the presence of cofactors, these should be identified and considered in patients with food allergy-not only for diagnosis, but also in treatment settings.

Treatment of Food Allergy: Immunotherapy, Omalizumab, or Both

Food allergy is a common disease that has substantial impacts on the quality of life of patients and their families, and all reactions have the potential for causing life-threatening anaphylaxis. Food-allergic individuals currently have 2 Food and Drug Administration- approved therapeutic options available to them aside from life-long allergen avoidance: oral immunotherapy (OIT) and omalizumab. OIT for food allergy has been extensively studied in clinical trials and currently provides the greatest level of protection; however, it also has a high burden of treatment. Studies suggest that more successful OIT outcomes may be attained with earlier intervention; however, early OIT presents its own challenges. Omalizumab, recently Food and Drug Administration-approved, is a biologic targeting IgE, a major driver of allergic reactions. In contrast to OIT, omalizumab monotherapy offers a low treatment burden therapeutic option that provides a safety net against reactions to accidental ingestion of multiple allergens. In addition, omalizumab has been investigated as an adjunct to OIT, improving the speed and safety of single-allergen or multiallergen OIT. Here, we discuss the clinical use of these therapeutic options and provide a guide for shared decision making between patients and physicians about what therapeutic option might be more appropriate.

New approaches in childhood IgE-mediated food allergy treatment

PURPOSE OF REVIEW

This review aims to provide an overview of the current and future treatment options for children with food allergies (FAs), highlighting the latest research findings and the potential impact of these new approaches on improving patients' and caregivers' quality of life.

RECENT FINDINGS

In the last decade, many promising approaches have emerged as an alternative to the standard avoidance of the culprit food with the risk of severe accidental reactions. Desensitization through oral immunotherapy has been introduced in clinical settings as a therapeutic approach, and more recently also omalizumab. In addition, alternative routes of administration for immunotherapy, other biologics, small molecules, probiotics or prebiotics, microbiota transplantation therapy, IGNX001, and PVX108 are being investigated.

SUMMARY

The portfolio of available treatment options for food allergies is increasing but several relevant unmet needs remain. This review aims to provide a brief overview of the existing and future treatment options for IgE-mediated food allergies.

Peanut Genotypes with Reduced Content of Immunogenic Proteins by Breeding, Biotechnology, and Management: Prospects and Challenges

Peanut allergies affect millions of people worldwide, often causing life-threatening reactions and necessitating strict avoidance. Recent advancements in oral immunotherapy, such as Palforzia™, and IgE-mediated treatments (e.g., Xolair), have improved care options; however, their high costs limit accessibility and widespread utility. To address these challenges, researchers are employing conventional breeding and advanced molecular tools, such as CRISPR editing, to develop peanut lines with reduced levels of major allergenic proteins (Ara h1, Ara h2, Ara h3, and Ara h6). These reduced-immunogenicity genotypes retain their agronomic viability, flavor, and nutritional quality to some extent, offering the potential for cost-effective oral immunotherapy and safe food options for use in public spaces by non-allergic individuals. Rigorous evaluation, including immunological assays and human feeding trials, is essential to confirm their effectiveness in reducing allergic reactions. Adoption will depend on the establishment of clear regulatory guidelines, stakeholder education, and transparent communication of the benefits and risks. With sustained research, public trust, and supportive policies, reduced-immunogenicity peanuts could substantially lower the global burden of peanut allergies. This communication examined the impact of peanut allergies worldwide and explored strategies to develop peanut genotypes with reduced allergen content, including conventional breeding and advanced genetic engineering. It also addressed the challenges associated with these approaches, such as policy and regulatory hurdles, and outlined key requirements for their successful adoption by farmers and consumers.

Comprehensive review of pollen-food allergy syndrome: Pathogenesis, epidemiology, and treatment approaches

Pollen-food allergy syndrome (PFAS) is caused by cross-reaction of a specific pollen antigen with the corresponding food allergen in sensitized individuals. The manifestations are usually limited to oral symptoms; however, sometimes, rhinitis, respiratory and skin symptoms, and anaphylactic shock may occur. In PFAS pathogenesis, when food containing protein antigens (pan-allergens) with high homology to pollen antigens is ingested, mast cells bound to pollen antigen-specific IgE distributed in the oral mucosa cross-react with the food antigen, causing a local type I allergic reaction. The prevalence of PFAS depends on the geographic conditions, such as the type and amount of pollen in the area. PFAS is prevalent in all regions owing to the wide variety of pollen antigens implicated in the disease, such as alder and grass pollen, even outside of the birch habitat area. Basic research on PFAS is expected to significantly contribute to elucidating the pathogenesis and development of therapeutic strategies for PFAS. Currently, effective treatment for patients with PFAS that allows safe consumption of raw foods is lacking, and avoiding the intake of causative foods is the basis of prevention. Furthermore, allergen immunotherapy for PFAS has not yet been established, but various attempts are underway to develop it into a novel treatment strategy. This review highlights the current research landscape on the pathophysiology, epidemiology, and clinical aspects of PFAS. We outline the research gaps that should be addressed to improve the outcomes of patients with PFAS.

Epicutaneous immunotherapy for the treatment of peanut allergy

Peanut allergy treatment options remain limited, but novel approaches are being studied, including epicutaneous immunotherapy (EPIT). EPIT uses the cutaneous immune system to promote tolerance to food allergens. Viaskin™ Peanut, an approach to EPIT in late-stage clinical development uses an occlusive patch with a condensation chamber that enables natural epidermal water loss to solubilize dry antigen on the patch, which is then absorbed and captured by skin Langerhans cells. This form of EPIT does not require disruption of the skin barrier, thus avoiding a proinflammatory cytokine response by targeting the nonvascularized epidermis and limiting systemic allergen exposure. Extensive preclinical research suggests that Viaskin Peanut has a distinct mechanism of desensitization, including the potential for disease modification, driven by a unique population of regulatory T cells. Numerous clinical studies of Viaskin Peanut have demonstrated desensitization and reductions in reaction severity, particularly in children aged 1 through 11 years, as well as a favorable safety profile with mostly mild-to-moderate skin reactions that were observed to decrease over time. EPIT with Viaskin Peanut may be a potential therapeutic option for peanut allergy that is clinically practical with long-term efficacy and tolerability.

Anti-IgE and food allergy

Food allergy is a growing problem that can have a significant impact on both the individual, the family, and society. We are entering a new era of food allergy management with the recent US Food and Drug Administration approvals of 2 therapies for food allergy. IgE is now known to play a critical role in allergic diseases, including food allergy. Ant-IgE therapy has been under investigation for decades and is now approved for asthma, urticaria, nasal polyps, and most recently, IgE-mediated food allergy. Here, we evaluate what is known about the safety and efficacy of anti-IgE therapy as monotherapy and in combination with oral immunotherapy. In addition, we will highlight important practical considerations and key knowledge gaps.

The use and implementation of omalizumab as food allergy treatment: Consensus-based guidance and Work Group Report of the Adverse Reactions to Foods Committee of the American Academy of Allergy, Asthma & Immunology

Omalizumab was recently approved by the US Food and Drug Administration for treatment of any single food allergy or multiple food allergies in children aged 1 year and older and adults. There is currently no formal guidance regarding recommended best practices for omalizumab use in food allergy, including patient selection, anticipated goals and outcomes of therapy, procedure for monitoring patients who elect to start omalizumab therapy, and ways in which omalizumab can be incorporated into the landscape of food allergy management and daily clinical practice. This work group report was developed by the food allergy therapies subcommittee of the Adverse Reactions to Foods Committee within the American Academy of Allergy, Asthma & Immunology. Consensus, evidence-based guidance regarding experts' recommendations for using omalizumab to treat children and adults with food allergy was developed by using modified Delphi methodology. In iterative fashion, a total of 8 statements regarding how to use omalizumab to treat patients with food allergy were developed by 16 clinical experts. This guidance provides the clinician with a suggested approach to patient selection, initiation of therapy, monitoring of efficacy, and long-term follow-up care. The role of preference-sensitive care is emphasized, with most statements offering care recommendations relevant to the culture and values of a particular practice setting.

Omalizumab safety concerns

IgE and mast cells play key roles in the pathophysiology of allergic diseases. In 2003, omalizumab was the first anti-IgE mAb licensed in the United States when initially US Food and Drug Administration-approved for the treatment of allergic asthma. Since that time, the number of US Food and Drug Administration-approved indications for treatment with omalizumab has grown to include chronic spontaneous urticaria, chronic rhinosinusitis with nasal polyps, and food allergy. Although omalizumab is generally considered relatively safe and well tolerated, a number of safety concerns have been raised since its initial approval. These concerns focus on specific adverse events of interest, including anaphylaxis, pregnancy, malignancy, cardiovascular events, and infections. For each of these issues, data from clinical trials and postmarketing surveillance have been evaluated extensively. In this review, we examine these safety data, provide context for safety and risk assessments, and summarize a safety profile for each of the adverse events of interest. In doing so, we aim to provide a resource for shared decision making when treatment with omalizumab is being considered.

Food allergy yardstick: Where does omalizumab fit?

Food allergy management has greatly evolved in the last several years, moving from passive approaches, such as strict food allergen avoidance, to more active treatments, including regulatory approval of the first specifically indicated immunotherapy product (for peanut) in 2020. In 2024, a second therapy, omalizumab, received regulatory approval for the treatment of 1 or more IgE-mediated food allergies, providing clinicians with multiple treatment options to offer patients and families. With this expanded armamentarium of food allergy treatment options, the practicing clinician requires detailed knowledge of benefits and risks of omalizumab, how omalizumab fits into the management landscape, and how to use shared decision-making to optimize therapy. This yardstick aims to provide the clinician with a review of data leading to omalizumab's food allergy indication and an evidence-based expert opinion approach regarding on how best to use this and other therapies available to optimize patient management.

Omalizumab with allergen immunotherapy in respiratory & food allergy

Allergen Immunotherapy (AIT) is the only disease modifying treatment option for patient with IgE mediated allergic disorder. Conventional subcutaneous immunotherapy is associated with adverse events during build-up and maintenance phase but cluster allergen immunotherapy with monoclonal anti-IgE antibody (omalizumab) has complementary and synergistic effect. Omalizumab plus AIT can significantly enhance the efficacy, safety, and steroid-sparing effect of AIT by increasing target maintenance dose (TMD) and sustained unresponsiveness (SU) to allergen while decreasing the adverse events and severe systemic reactions. This review aims to highlight that combination of omalizumab plus AIT is superior than AIT alone.

Role of allergen immunotherapy and biologics in allergic diseases

The rise in the prevalence of allergic diseases has become a global health burden. Allergic diseases are a group of immune-mediated disorders characterized by IgE-mediated conditions resulting from a type 2 helper T cell (Th2)-skewed immune response. This review aims to comprehensively summarize recent research on the roles of allergen immunotherapy (AIT) and biologics in allergic diseases. Specifically, we review the mechanisms of AIT and biologics in modulating innate and adaptive immunity involved in allergic disease pathogenesis, as well as their safety and efficacy in the treatment of allergic diseases. We also discuss current new AIT strategies such as recombinant allergen-based vaccines and allergen extract nanoencapsulation. Further research is needed to understand immune tolerance mechanisms beyond the Th2 pathway and to characterize immunological changes in responders and nonresponders to AIT or biologics. This additional research may uncover new targets for monitoring treatment responses and developing personalized treatment strategies for allergic diseases.

Biological Effects and Clinical Application of the Anti-Immunoglobulin E Antibody

BACKGROUND

Immunoglobulin E (IgE) plays a pivotal role in the pathogenesis of allergic diseases by engaging with FcεRI and FcεRII receptors, triggering allergic responses. The development of anti-IgE antibodies, such as omalizumab, has introduced a targeted approach to allergy treatment by neutralizing free IgE and dampening the allergic cascade.

SUMMARY

This review synthesizes the current understanding of IgE's role in allergic diseases and evaluates the clinical utility of omalizumab. It specifically examines the biological mechanisms underpinning anti-IgE antibodies and their efficacy in treating moderate to severe asthma and chronic spontaneous urticaria (CSU). The paper also explores the potential of omalizumab in managing other allergic conditions and considers the long-term implications of anti-IgE therapy.

KEY MESSAGES

By summarizing and elucidating the biological mechanisms and clinical applications of anti-IgE antibodies through a review of global literature from the past 5 years, this article aims to establish a theoretical foundation for developing innovative anti-allergic treatment strategies. Omalizumab has demonstrated efficacy in reducing IgE-mediated responses, offering improved clinical outcomes for patients with asthma and CSU, with promising potential in an array of allergic diseases. The long-term safety profile of anti-IgE medications remains an area of active investigation, underscoring the need for ongoing research to refine these therapies and expand their application in allergy management.

GA2LEN ANACARE consensus statement: Potential of omalizumab in food allergy management

Immunoglobulin E (IgE)-mediated food allergies are the most common type of food allergy, often causing rapid symptoms after exposure to allergens posing a serious health risk and a high impact on patient's and caregiver's quality of life. Omalizumab, a humanized anti-IgE monoclonal antibody, reduces allergic reactions by binding to circulating IgE. Omalizumab has been successfully used in allergic asthma, chronic rhinosinusitis with nasal polyps, and chronic urticaria, and was recently approved for treating IgE-mediated food allergies by the US Food and Drug Administration (FDA). This GA2LEN ANACARE Consensus Statement presents our position on the use of omalizumab for treating IgE-mediated food allergies, based on a systematic review and meta-analysis, experience with use for other conditions, and expert consensus achieved via an eDelphi process. Following publication of the recent OUtMATCH study (stage 1) results and subsequent FDA approval, we propose that there is now sufficient evidence to recommend omalizumab as the only drug currently available that can mechanistically reduce IgE-mediated food allergic reactions. We acknowledge that the evidence does not reach the highest level of evidence which would be needed for a guideline recommendation.

Omalizumab Implementation in Practice: Lessons Learned From the OUtMATCH Study

In February 2024, omalizumab was approved by the U.S. Food and Drug Administration for the treatment of food allergy, based on data from the landmark phase 3 clinical trial, Omalizumab as Monotherapy and as Adjunct Therapy in Children and Adults (OUtMATCH). In this Rostrum, OUtMATCH investigators share their perspectives on the trial results, the implications for translation into daily practice, and on remaining gaps in the field. The study met its primary and key secondary end points, demonstrating a large effect size in multiallergen desensitization compared with placebo; yet there were some participants who did not respond, and the percentage of responders tolerating all 3 food allergens was lower than that for single foods. Clinicians are likely to have many questions about appropriate patient selection, monitoring for treatment responsiveness, and how to manage off-label considerations such as dietary incorporation or cotreatment with oral immunotherapy. Additional research is needed to answer these remaining questions and ensure that the translation of omalizumab in real-world practice leads to high-quality outcomes.

Biologics in Food Allergies: Emerging Therapies

Immunoglobuin E (IgE)-mediated food allergies greatly impact patients and their families, causing financial and emotional stress, and placing them at risk for lifethreatening reactions. Until recently, food allergies have been treated with allergen avoidance and emergency treatment of allergic reactions. Omalizumab was recently approved in adults and children greater than one year who are allergic to one or more foods for the prevention of serious allergic reactions in the setting of accidental exposure. Omalizumab also shows promise when combined with oral immunotherapy for possible allergen ingestion. Other classes of biologics and small molecule inhibitors have also demonstrated potential for use in preventing and treating food allergy.

[Efficacy of biologics for severe asthma on allergic comorbidities]

Identification of therapeutic targets other than asthma can guide the choice of biologics in cases of severe asthma. Some of the allergic diseases (atopic dermatitis, food allergies, allergic rhinoconjunctivitis) that may be associated with asthma can be treated with biologics. In this review, we aim to assess the effectiveness of these biologic therapies on the allergic comorbidities of asthma. In the treatment of atopic dermatitis, only Dupilumab, an anti-IL4Rα, has proven its effectiveness and has received reimbursement authorization for this indication. In patients presenting with allergic rhinoconjunctivitis, Omalizumab has shown effectiveness, but has not been approved for this indication. Data from post-hoc analyses of studies on severe asthma likewise suggest the effectiveness of Dupilumab regarding allergic rhinitis. While these two biologic therapies have shown positive signals, inducing oral food tolerance, the relevant data are not robust. Biologic therapies targeting IL-5 or its receptor (Mepolizumab, Benralizumab) have seldom been evaluated in allergic comorbidities, excepting atopic dermatitis, for which their effectiveness has not been proven. Lastly, there are interesting data on the combination of biologic therapy and allergen immunotherapy in cases of allergic rhinitis and food allergies, but they need to be confirmed by randomized studies.

The use of biologics in food allergy management

Patients and families living with food allergy may experience significant burdens, including social isolation, impaired quality of life, and anxiety. Allergists/immunologists play a critical role in educating families living with food allergies about risk, particularly with regard to the rarity of fatal food allergy. Appropriate risk framing can greatly decrease the fear-based burden of disease. In 2024, an increasing complex fabric of food allergy treatments has emerged that includes oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and omalizumab, with the promise of additional treatments, including epicutaneous immunotherapy and oral mucosal immunotherapy in the near future. Younger children may be most likely to benefit from OIT and SLIT, with some evidence that suggests the possibility of an immunomodulatory effect. Omalizumab, approved in 2024 for use in conjunction with strict avoidance, increases the threshold of reactivity before a moderate-to-severe reaction for many, but not all, patients. There is no evidence to date that omalizumab has an immunomodulatory effect, and young children treated with omalizumab monotherapy may bear a lost opportunity cost from possible immunomodulation would they have been treated with OIT or SLIT instead; however, within a shared decision-making paradigm, beyond label use of omalizumab may include treatment with OIT or SLIT. Fortunately, the co-evolution of shared decision-making with modern food allergy treatments will facilitate the critical preference-sensitive care that must be characteristic of all decisions surrounding active food allergy management.

A case report of food-dependent exercise-induced anaphylaxis (FDEIA) treated with omalizumab

Food-dependent exercise-induced anaphylaxis (FDEIA) is a rare and complex clinical condition in which allergic reactions are triggered by specific foods combined with physical activity, even though the food allergen and exercise are tolerated individually. Wheat is the most common culprit food leading to wheat dependent exercise induced anaphylaxis (WDEIA). Management of FDEIA is challenging due to the unpredictability of attacks and the lack of approved prophylactic medications. This report presents a case of successful symptom control in a young woman with WDEIA through the addition of omalizumab to the treatment regimen. To our knowledge, this is the first reported case of food-dependent exercise-induced anaphylaxis (FDEIA) treated with omalizumab as the primary indication. We also summarize the pathophysiology, diagnosis and treatment of FDEIA. The need for heightened awareness and innovative therapeutic approaches is crucial for those affected by FDEIA.

Patient-Reported Outcome Measures in Food and Drug Allergy

A patient-reported outcome is directly reported by the patient without interpretation of the patient's response by anyone else. It refers to the patient's health (symptoms and feelings), quality of life, or functional status associated with health care or treatment. Patient-reported outcome measures (PROMs) are defined as the tools or instruments that are used to measure patient-reported outcomes. Health-related quality of life has been the most studied psychosocial PROM in food allergy, using validated questionnaires. In drug allergy, PROMs are useful in capturing patients' experiences of potential allergic reactions, including subjective symptoms such as headache, dizziness, or fatigue. Patient-reported outcome measures can also help differentiate true allergies from side effects or other nonallergic reactions and inform decisions about drug challenges and de-labeling strategies. Ensuring the chosen tool is validated for the specific allergy context is crucial for accurate data collection. Integrating patient-reported experiences alongside traditional methods can lead to more accurate assessments and personalized care.

The Role of Food Allergy in Atopic Dermatitis

Atopic dermatitis (AD) and food allergies are 2 atopic conditions that tend to develop early in life. Their interrelationship has been a topic of controversy and many studies. The presence of atopic dermatitis in infancy and early childhood, particularly if severe, is a risk factor for the development of immunoglobulin E (IgE) -mediated food allergies. While it is common for children with AD to demonstrate extensive sensitization to foods, serum IgE testing is not always indicative of clinical allergy.

A Media Advocacy Toolkit for the Allergist-Immunologist

For clinicians involved in improving healthcare for patients with allergic and immunologic conditions, advocacy on a broader level through public outreach is key to advancing value-based care. In this article, we provide a toolkit of strategies and resources that can be used to raise public awareness of important issues through various mediums, including podcasts and social media, newspapers, testimonies, presentations, and interviews. A simple approach to effective media interactions is described using the acronym "RATIO," which stands for Research, Audience, Targeted topic, Interview rephrasing, and Optimism. The acronym also reminds the person who is presenting information that only a fraction of what is discussed will be recalled, and an even smaller proportion will be implemented. Key points should be made early. Examples of key talking points are provided for selected topics, including food allergy, anaphylaxis, asthma, rhinitis, and broader healthcare advocacy.

New evidence in food allergies treatment

PURPOSE OF REVIEW

To acknowledge, the newly available treatments for food allergy described in the latest scientific literature, such as oral immunotherapy (OIT), biologics and the combination of them in managing patients with IgE-mediated food allergies.

RECENT FINDINGS

Recent studies suggest that OIT and biologics, alone or together, can have a role as disease-modifying treatments for food allergies. The FDA has recently approved omalizumab as a treatment for food allergy. Other biologics are currently under evaluation and further studies are needed to assess the efficacy and safety of these therapies.

SUMMARY

The allergology scenario is rapidly evolving, the recent introduction and approval of new therapeutic strategies such as biotechnological drugs and allergen immunotherapy is changing the therapeutic paradigm: we are witnessing a shift from a strategy based on avoiding the trigger and reversing an allergic reaction already in progress, to one that aims to modify the natural history of the disease by acting on the immunological mechanisms that determine it. This approach is consistent with the modern perspective of a personalized patient-tailored medicine. In this opinion review, we will provide a brief analysis of current and future therapeutic options for IgE-mediated food allergy, focusing on OIT, biologics and their combination.

Immunotherapy and biologics in the management of IgE-mediated food allergy: Systematic review and meta-analyses of efficacy and safety

Food allergy (FA) is a potentially life-threatening chronic condition that is becoming an increasing public health problem worldwide. This systematic review (SR) was carried out to inform the development of clinical recommendations on the treatment of IgE-mediated FA with biologics and/or IT for the update of the EAACI guidelines. A SR of randomized-controlled trials or quasi-controlled trials was carried out. Studies were identified via comprehensive search strategies in Medline, Embase, and Cochrane Library, up to April 2022.

POPULATION

Human adults, children, and adolescents with IgE-mediated FA.

INTERVENTION

IT and/or biologics.

COMPARATOR

Placebo or standard-of-care (allergen avoidance).

OUTCOME

Efficacy (desensitization, sustained unresponsiveness (SU), remission), quality of life, and safety (systemic and local adverse reactions (AR)). The Cochrane RoB tool was used to assess the risk of bias. It was reported according to PRISMA and registered in PROSPERO CRD4202229828. After screening, 121 studies were included (111 for IT and 10 for biologics). Most studies had a high risk of bias and showed high heterogeneity in design and results. Metanalysis showed a positive effect of biologics and IT in terms of relative risk (RR) for achieving tolerance to the culprit food compared to avoidance or placebo. Omalizumab for any FA showed a RR of 2.17 [95% confidence interval: 1.22, 3.85]. For peanut allergy, oral IT (OIT) had a RR of 11.94 [1.76, 80.84] versus avoidance or placebo, sublingual IT (SLIT) had a RR of 3.00 [1.04, 8.66], and epicutaneous IT (EPIT) of 2.16 [1.56, 3.00]. OIT had a RR of 5.88 [2.27, 15.18] for cow's milk allergy, and of 3.43 [2.24, 5.27] for egg allergy. There was insufficient data on SLIT or EPIT for the treatment of egg and milk allergies. Most ARs reported were mild. For OIT the most common AR involved the gastrointestinal system and for EPIT, AR's most commonly affected the skin. There was limited data on severe or life-threatening ARs. There was limited evidence for long term efficacy and quality of life. In conclusion, biologics and IT, alone or in combination, are effective in achieving desensitization while on active treatment but more evidence is needed on long-term tolerance as current evidence is not of high quality. Adverse events while on therapy are generally mild to moderate but a long-term comprehensive safety profile is missing. There is a critical need to optimize and standardize desensitization protocols and outcome measures to facilitate our understanding of the efficacy and safety as well as to allow for comparison between interventions.

Tick bites, IgE to galactose-alpha-1,3-galactose and urticarial or anaphylactic reactions to mammalian meat: The alpha-gal syndrome

The recent recognition of a syndrome of tick-acquired mammalian meat allergy has transformed the previously held view that mammalian meat is an uncommon allergen. The syndrome, mediated by IgE antibodies against the oligosaccharide galactose-alpha-1,3-galactose (alpha-gal), can also involve reactions to visceral organs, dairy, gelatin and other products, including medications sourced from non-primate mammals. Thus, fittingly, this allergic disorder is now called the alpha-gal syndrome (AGS). The syndrome is strikingly regional, reflecting the important role of tick bites in sensitization, and is more common in demographic groups at risk of tick exposure. Reactions in AGS are delayed, often by 2-6 h after ingestion of mammalian meat. In addition to classic allergic symptomatology such as urticaria and anaphylaxis, AGS is increasingly recognized as a cause of isolated gastrointestinal morbidity and alpha-gal sensitization has also been linked with cardiovascular disease. The unusual link with tick bites may be explained by the fact that allergic cells and mediators are mobilized to the site of tick bites and play a role in resistance against ticks and tick-borne infections. IgE directed to alpha-gal is likely an incidental consequence of what is otherwise an adaptive immune strategy for host defense against endo- and ectoparasites, including ticks.

A practical guide for implementing omalizumab therapy for food allergy

The recent approval of omalizumab for the treatment of IgE-mediated food allergy is an important step forward for the millions of food allergy patients in the United States. Through the depletion of circulating IgE and the subsequent reduction of FcεR1 on key effector cells, patients increase their tolerance to food allergens. However, omalizumab does not permit patients to eat foods that they are allergic to with impunity. Rather, it protects them from most accidental exposures. In addition, omalizumab does not cure food allergy and has not demonstrated true immunomodulation. Thus, omalizumab might be a lifelong therapy for some patients. Furthermore, there are many important questions and issues surrounding the appropriate administration of omalizumab to treat food allergy, which we discuss. Managing treatment of patients with disease that falls outside the dosing range, assessing treatment response or nonresponse, addressing its appropriateness for patients older than 55, and determining whether immunotherapy plus omalizumab provides any advantage over omalizumab alone all need to be examined. Identifying appropriate patients for this therapy is critical given the cost of biologics. Indeed, not all food allergy patients are good candidates for this therapy. Also, when and how to stop omalizumab therapy in patients who may have outgrown their food allergy needs to be elucidated. Thus, although this therapy provides a good option for patients with food allergies, much information is needed to determine how best to use this therapy. Despite many unanswered questions and issues, we provide clinicians with some practical guidance on implementing this therapy in their patients.

Perspectives in precautionary allergen labelling of prepackaged foods after the FAO/WHO consultation

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of the perspectives regarding precautionary allergen labelling (PAL) of prepackaged foods following the consultation conducted by the Food and Agriculture Organization (FAO) and the WHO.

RECENT FINDINGS

The FAO/WHO consultation provided a comprehensive assessment of the current status and practices of PAL implementation worldwide. One of the key findings highlighted by the Expert Committee was the need for improvement in existing PAL systems. It was noted that many countries lacked uniformity in PAL practices, leading to inconsistencies in labelling and potentially misleading information for consumers. Furthermore, the consultation emphasized the importance of PAL being risk-based, taking into account both the amount and frequency of unintended allergen presence (UAP) in food products.

SUMMARY

The FAO/WHO consultation shed light on various perspectives and challenges associated with PAL of prepackaged foods. Key findings emphasized the need for improvement in existing PAL systems, including the adoption of a risk-based approach, standardized regulations, and enhanced transparency. Moving forward, collaborative efforts between regulatory agencies, food manufacturers, and consumer advocacy groups will be essential in developing effective PAL strategies that prioritize consumer safety and well being.

Role of biologics in severe food allergy

PURPOSE OF REVIEW

This review examine the dynamic landscape of food allergy treatment within the context of emerging biologics. Our purpose is to comprehensively evaluate the potential benefits, challenges, and transformative impact associated with the utilization of biologics in comparison to conventional therapeutic modalities.

RECENT FINDINGS

This document synthesizes recent scientific investigations to various biologics, such as omalizumab, ligelizumab, dupilumab, and tezepelumab, providing a nuanced understanding of their roles in oral immunotherapy, rapid desensitization, and overall food allergy management. Recent studies and clinical trials highlight the impact of anti-IgE treatment on food allergies, revealing critical findings such as dose-related efficacy, facilitation of rapid desensitization in peanut allergies, and the sustained positive outcomes observed in individuals with multifood allergies.

SUMMARY

The use of biologics presents a groundbreaking approach in the treatment of food allergies. The multifaceted action of these agents, along with their potential to overcome the challenges associated with traditional therapies, marks a significant advancement. Despite the persisting challenges of economic constraints and the need for further safety studies, biologics offer a promising avenue for improving the quality of life for individuals with food allergies. Ongoing research and collaborative efforts are imperative to fully realize the transformative potential inherent in these emerging therapeutic frontiers.

Management of food allergy based on oral food challenge

PURPOSE OF REVIEW

Food allergy is a growing health problem that affects both patients and society in multiple ways. Despite the emergence of novel diagnostic tools, such as component-resolved diagnostics (CRD) and basophil activation tests (BAT), oral food challenge (OFC) still plays an indispensable role in the management of food allergies. This review aimed to highlight the indications and safety concerns of conducting an OFC and to provide insights into post-OFC management based on recent findings.

RECENT FINDINGS

Standardized OFC protocols have regional diversification, especially in Japan and Western countries. Recent studies suggested that the interval between doses should be at least more than an hour. Furthermore, applying a stepwise method tailored to the patient's specific immunoglobulin E level and history of anaphylaxis seems to mitigate these risks. Recent surveys have shown that, following a positive OFC, options other than strict avoidance are also selected.

SUMMARY

OFC serves diverse purposes, yet the risks it carries warrant caution. The stepwise protocol appears promising for its safety. Subthreshold consumption following OFC shows potential; however, further research on its efficacy and safety is required. Management following OFC should be tailored and well discussed between clinicians and patients.

New biologics for food allergy

PURPOSE OF REVIEW

This review aims to explore role of emerging biologics, including ligelizumab, UB-221, dupilumab, and antialarmins, in food allergy management. With a focus on recent developments, we evaluate their promise in mitigating adverse events during oral immunotherapy (OIT), reducing allergic reactions, and addressing the limitations of current therapeutic options.

RECENT FINDINGS

Antiimmunoglobulin E mAbs, exemplified by omalizumab, demonstrate efficacy in desensitization and safety improvement during multiallergen OIT. Next-generation antibodies like ligelizumab and UB-221 exhibit enhanced potency and unique mechanisms, holding promise for food allergy treatment. Dupilumab, targeting IL-4 receptor alpha, presents potential benefits in decreasing allergen-specific IgE and modifying the atopic march. Exploration of antialarmins, specifically anti-IL-33 (etokimab) and anti-TSLP (tezepelumab), reveals encouraging results, with etokimab showing early success in peanut allergy trials.

SUMMARY

Biologics hold promising potential for food allergy treatment. Tailoring therapeutic approaches based on shared decision-making becomes pivotal. While omalizumab remains a significant option, next-generation anti-IgE antibodies and agents targeting alarmins exhibit unique strengths. Dupilumab, despite limited success as monotherapy, shows promise as an adjunct for OIT. Careful consideration of treatment goals, patient preferences, and the evolving landscape of biologics will shape future clinical practice, offering allergists an expanded toolbox for personalized food allergy management.

The role of pediatricians in the diagnosis and management of IgE-mediated food allergy: a review

Importance

Food allergy can often cause a significant burden on patients, families, and healthcare systems. The complexity of food allergy management requires a multidisciplinary approach involving different types of healthcare providers, including allergists, dieticians, psychologists, nurses, family practitioners and, of particular relevance for this article, pediatric primary caretakers. Pediatricians may be the first-line healthcare providers for food allergy: strategies for management and guideline adherence have been highlighted.

Observations

This review article summarizes the up-to-date recommendations on the role of pediatricians in the diagnosis, management, and prevention of IgE-mediated food allergy. Early introduction of allergenic foods like peanut is known to be of importance to reduce the development of peanut allergy in infants, and pediatricians are essential for educating and supporting parents in this decision. In scenarios of limited allergist availability, as is often the case among rural, Medicaid and minority populations, pediatricians can assist in the evaluation and management of food allergy, and provide action plans, education and counselling for patients and families.

Conclusions and relevance

Pediatric primary caretakers play a key role in the diagnosis, management, and prevention of IgE-mediated food allergy. As more diagnostic tools and therapies in food allergy become available, the need for a multidisciplinary team is paramount to optimize patient care.

Differences in the Course, Diagnosis, and Treatment of Food Allergies Depending on Age-Comparison of Children and Adults

Food allergy (FA) has become a common global public health issue, with a growing prevalence in the modern world and a significant impact on the lives of patients, their families, and caregivers. It affects every area of life and is associated with elevated costs. Food allergy is an adverse immune reaction that occurs in response to a given food. The symptoms vary from mild to severe and can lead to anaphylaxis. This is why it is important to focus on the factors influencing the occurrence of food allergies, specific diagnostic methods, effective therapies, and especially prevention. Recently, many guidelines have emphasized the impact of introducing specific foods into a child's diet at an early age in order to prevent food allergies. Childhood allergies vary with age. In infants, the most common allergy is to cow's milk. Later in life, peanut allergy is more frequently diagnosed. Numerous common childhood allergies can be outgrown by adulthood. Adults can also develop new IgE-mediated FA. The gold standard for diagnosis is the oral provocation test. Skin prick tests, specific IgE measurements, and component-resolved diagnostic techniques are helpful in the diagnosis. Multiple different approaches are being tried as possible treatments, such as immunotherapy or monoclonal antibodies. This article focuses on the prevention and quality of life of allergic patients. This article aims to systematize the latest knowledge and highlight the differences between food allergies in pediatric and adult populations.

Hot topics in allergen immunotherapy, 2023: Current status and future perspective

The importance of allergen immunotherapy (AIT) is multifaceted, encompassing both clinical and quality-of-life improvements and cost-effectiveness in the long term. Key mechanisms of allergen tolerance induced by AIT include changes in memory type allergen-specific T- and B-cell responses towards a regulatory phenotype with decreased Type 2 responses, suppression of allergen-specific IgE and increased IgG1 and IgG4, decreased mast cell and eosinophil numbers in allergic tissues and increased activation thresholds. The potential of novel patient enrolment strategies for AIT is taking into account recent advances in biomarkers discoveries, molecular allergy diagnostics and mobile health applications contributing to a personalized approach enhancement that can increase AIT efficacy and compliance. Artificial intelligence can help manage and interpret complex and heterogeneous data, including big data from omics and non-omics research, potentially predict disease subtypes, identify biomarkers and monitor patient responses to AIT. Novel AIT preparations, such as synthetic compounds, innovative carrier systems and adjuvants, are also of great promise. Advances in clinical trial models, including adaptive, complex and hybrid designs as well as real-world evidence, allow more flexibility and cost reduction. The analyses of AIT cost-effectiveness show a clear long-term advantage compared to pharmacotherapy. Important research questions, such as defining clinical endpoints, biomarkers of patient selection and efficacy, mechanisms and the modulation of the placebo effect and alternatives to conventional field trials, including allergen exposure chamber studies are still to be elucidated. This review demonstrates that AIT is still in its growth phase and shows immense development prospects.

Combination of omalizumab with allergen immunotherapy versus immunotherapy alone for allergic diseases: A meta-analysis of randomized controlled trials

BACKGROUND

Allergen immunotherapy (AIT)-associated adverse events (AEs) limit its usage in the management of allergic diseases. The monoclonal anti-IgE antibody (omalizumab) and AIT have complementary actions. However, no consensus has been reached on whether their combination could exert superior efficacy and safety.

OBJECTIVE

To evaluate whether the combination of AIT with omalizumab is superior to AIT alone in treating allergic diseases.

METHODS

The MEDLINE/PubMed, Embase, Scopus and Cochrane Library databases were searched to identify randomized control trials (RCTs) reporting the outcomes of omalizumab combined with AIT (omalizumab + AIT) versus AIT alone. A random-effect model was established to estimate outcomes with a 95% confidence interval (CI).

RESULTS

A total of 11 eligible RCTs (involving 901 patients) were screened out for the meta-analysis. According to a pooled analysis, omalizumab + AIT significantly increased the number of patients achieving the target maintenance dose (TMD) and sustained unresponsiveness (SU) to allergens (odds ratio [OR] = 2.43; 95% CI: 1.33-4.44; p = 0.004; I2 = 35%, and OR = 6.77; 95% CI: 2.10-21.80; p = 0.001; I2 = 36%, respectively). Similarly, individuals receiving the combination therapy reported significantly fewer episodes of severe systemic AEs than AIT alone (OR = 0.32; 95% CI: 0.18-0.59; p = 0.0003; I2 = 0%). Meanwhile, the improvements in symptom severity score (mean difference [MD] = -0.26), rescue medication daily means score (MD = -0.14), and number of patients consuming epinephrine in AIT (OR = 0.20) were all more evident than those in AIT alone.

CONCLUSION

Omalizumab + AIT can significantly enhance the efficacy and safety of AIT by increasing TMD and SU to allergens, while decreasing severe systemic AEs.

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.).

Eosinophilic gastritis and gluten-sensitive enteropathy manifested as hypoproteinemia and treated with omalizumab: a case report

BACKGROUND

Eosinophilic gastritis (EoG) has rarely been reported in conjunction with gluten-sensitive enteropathy (GSE). When this does occur, patients typically present with gastrointestinal symptoms. To our knowledge, hypoproteinemia has not been reported as the primary manifestation. Anti-IgE therapy, such as omalizumab, lowers eosinophil counts in the blood, lungs, and gut. Its efficiency in treating active EoG remain unknown.

CASE PRESENTATION

We report a 33-month-old boy with a history of food allergy and atopic dermatitis who developed recurrent edema, hypoproteinemia, and eosinophilia at the age of 14 months. The diagnoses of EoG and GSE were confirmed based on the clinical presentation and results of gastrointestinal biopsies and serological testing. Although prednisone and dietary intervention were initially effective, the boy developed prednisone-related facial swelling. After stopping prednisone, his symptoms relapsed. Subsequent treatment with omalizumab, combined with dietary intervention, showed good efficacy and safety.

CONCLUSIONS

To our knowledge, this is the first case of concurrent EoG and GSE that presented primarily with hypoproteinemia. We highlight the rare manifestations of these two diseases to raise clinical suspicion and prevent missed and delayed diagnoses. The pathogenesis of EoG is heterogeneous and complex. Omalizumab showed good efficacy, indicating that IgE-mediated processes may be involved in the pathogenesis of this patient's diseases.

Comprehensive Diagnosis, Management, and Treatment of Sesame Allergy

Sesame allergy prevalence varies regionally and by age, in the range of 0.1% to 0.9%. Reactions can be severe and potentially fatal. Resolution rates are in the range of 20% to 50%. The diagnosis requires a careful history and the use of tests, such as skin prick tests and serum sesame-specific IgE. The availability of serum IgE testing for the sesame protein Ses i 1 has improved diagnostic accuracy. The emerging potential for sesame basophil activation tests and additional new tests will likely improve diagnosis in coming years, further reducing the need for diagnostic oral food challenges. Although sesame proteins share homology with those in many foods, clinically relevant cross-reactivity appears uncommon. Nevertheless, sesame is a prominent allergen for those with multiple food allergies. Management may include strict avoidance, but sesame products vary dramatically in protein content. Many people with sesame allergy tolerate forms that are low in protein, such as scattered seeds, rather than sesame paste that is protein-dense. Thus, options in the approach to avoidance are possible. Studies suggest that sesame oral immunotherapy may be safe and effective, and this and additional treatment options are emerging. Here, we review the current comprehensive diagnosis, management, and treatment for sesame allergy.

Utility of food allergy thresholds

Food allergy is a prevalent disease worldwide that is a significant quality-of-life burden, and accidental exposures to food allergens may elicit severe, life-threatening reactions such as anaphylaxis. The threshold level, or the dose that triggers an allergic reaction determined by oral food challenges, varies considerably among individuals suffering from food allergies. Moreover, IgE concentration, diversity, or function can only partially explain this variation in threshold; pathogenic effector TH2 cells have also been found to contribute to the eliciting dose. Though very sensitive to cofactors such as physical activity/stress, the threshold is a stable and reproducible feature of an individual's allergy over periods of many months, made clear in the past several years from treatment studies in which repeated threshold determination has been used as a treatment outcome; however, there also seem to be age-related changes at a population level. More routine determination of food allergy thresholds may help patients stratify risk to improve the management of their food allergy. Precautionary allergen labeling, such as "may contain" labels, often causes confusion since they are inconsistent and regularly contain little to trace allergen residues; thus, food products with such labeling may be unnecessarily avoided. Population-based eliciting dose levels have been determined in the literature; patients at lower risk with higher thresholds may be more confident with introducing foods with precautionary allergen labels. Understanding a patient's threshold level could aid in shared decision-making to determine the most suitable treatment options for patients, including the starting dose for oral immunotherapy and/or the use of biologics.