Can we identify patients at risk of life-threatening allergic reactions to food?

Use of the DEFASE score in research trials

PURPOSE OF REVIEW

To explore the potential applicability in clinical trials of the groundbreaking international consensus named DEFASE (DEfinition of Food Allergy SEverity) as the unique grading system for IgE-mediated food allergy (FA) severity embracing the different aspects of the disease in a holistic approach. Herein, we discuss its relevance in clinical trials and potential applications in research and clinical settings through a few clinical scenarios.

RECENT FINDINGS

The DEFASE score has been developed to be used in research settings as a comprehensive scoring system. Researchers are currently focusing on internal and external validation of the scoring system, targeting these models to various food allergenic sources, populations, and settings.

SUMMARY

Implementing the DEFASE score in clinical trials could improve patient stratification, guide therapeutic decisions, and support regulatory assessments. Future research will focus on its external validation and integration with biomarker data to refine its predictive accuracy and make this tool applicable in the near future.

Exploring the potential link between vegetable oil supplementation and adverse food reactions in dogs: a preliminary study

BACKGROUND

Adverse food reactions (AFR) are a common cause of skin diseases in dogs, with a prevalence of up to 24%. Research in humans and mice has shown that a high intake of vegetable oils rich in omega-6 polyunsaturated fatty acids (n-6 PUFA) can increase the risk and severity of allergic diseases. This study aimed to investigate the association between AFR and the supplementation of vegetable oils in the canine diet.

RESULTS

A total of 459 dogs were analyzed, with atopic dermatitis (22.66%) and adverse food reactions (AFR) (8.06%) being the most common diagnoses. Oil supplementation was recorded in 14.16% of dogs, with extra-virgin olive oil being the most common (70.77%). Dogs with AFR and concurrent AFR and CAD showed significantly higher oil supplementation rates compared to other conditions (P < 0.05; P < 0.001). No significant association was found between oil type and diagnosis (P = 0.563). After excluding EFA-supplemented dogs and those on prescription dermo diets, oil supplementation was still more prevalent in dogs with AFR compared to other conditions (29.31% vs. 10.10%, P < 0.001).

CONCLUSIONS

Vegetable oil supplementation was more frequent in dogs with AFR than in those with other dermatological conditions. This is the first study to evaluate the relationship between vegetable oil supplementation and AFR in dogs. While vegetable oil supplementation is associated with AFR, further studies are needed to establish causality and better understand the role of n-6 PUFA in the development of food allergies in dogs.

Omega-5-Gliadin Allergy and Cofactors Leading to Anaphylaxis: A Case Report

Anaphylaxis, a potentially life-threatening systemic reaction, is an increasingly common reason for emergency department (ED) admissions, which often poses diagnostic challenges. We present a case of a 62-year-old man who had recurrent anaphylaxis, initially suspected to be triggered by non-steroidal anti-inflammatory drugs (NSAIDs). By conducting thorough history-taking and comprehensive allergy testing, we identified allergic sensitization to the omega-5-gliadin (O5G) component of gluten, which manifested only when wheat consumption was accompanied by specific factors, notably exercise or NSAID use. He was diagnosed eight years after the first anaphylactic episode with wheat-dependent exercise-induced anaphylaxis (WDEIA). Adherence to a gluten-free diet effectively prevented further episodes. This case underscores the importance of emergency physicians not only in treating anaphylaxis but also in recognizing rare diagnoses, such as cofactor-enhanced food-induced allergic reactions, and understanding their management. This awareness is critical not only for conducting comprehensive assessments in collaboration with allergy specialists but also for facilitating earlier diagnosis, educating patients about the use of epinephrine auto-injectors, and emphasizing essential avoidance measures to prevent the recurrence of anaphylaxis.

Microbial metabolism of food allergens determines the severity of IgE-mediated anaphylaxis

Anaphylaxis is an acute, potentially life-threatening reaction, often triggered by foods and largely mediated by IgE. A critically important aspect of anaphylaxis pertains to the factors that modulate its severity. The human microbiota is known to influence oral tolerance, but the microbial mechanisms directly involved in IgE-mediated anaphylaxis remain unknown. Here, we demonstrate that human saliva harbors peanut-degrading bacteria that metabolize immunodominant allergens (Ara h 1 and Ara h 2) and alter IgE binding. Additionally, we provide in vivo evidence showing that oral bacteria metabolize peanut allergens, influencing systemic allergen exposure and the severity of anaphylaxis. Finally, in a clinical study, we observe that common peanut-degrading bacteria, such as Rothia, from the oral cavity, are more abundant in peanut-allergic patients who exhibit better tolerance to allergen exposure. Altogether, these results demonstrate the role of the human microbiota in modulating IgE-mediated reactions through allergen metabolism. These findings reveal a novel microbial mechanism with potential to prevent, or reduce, the severity of IgE-mediated anaphylaxis.

The role of neutrophils in allergic disease

Neutrophils are short-lived cells of the innate immune system and represent 50-70% of the circulating leucocytes. Their primary role is antimicrobial defence which they accomplish through rapid migration to sites of inflammation followed by phagocytosis, degranulation, and the release of neutrophil extracellular traps (NETosis). While previously considered terminally differentiated cells, they have been shown to have great adaptability and to play a role in conditions ranging from cancer to autoimmunity. This review focuses on their role in allergic disease. In particular: their role as potential amplifiers of type 1 hypersensitivity reactions leading to anaphylaxis; their involvement in alternative pathways of food and drug allergy; their role in allergic rhinitis and asthma and neutrophil dysfunction in atopic dermatitis. The use of potential biomarkers and therapeutic targets is also discussed with a view to guiding future research.

Effects of Food Processing on Allergenicity

PURPOSE OF REVIEW

There is an increasing awareness among clinicians that industrial and household food processing methods can increase or decrease the allergenicity of foods. Modification to allergen properties through processing can enable dietary liberations. Reduced allergenicity may also allow for lower risk immunotherapy approaches. This review will equip physicians, nurses, dieticians and other health care providers with an updated overview of the most clinically oriented research in this field. We summarize studies assessing the allergenicity of processed foods through clinically accessible means, such as oral food challenges, skin prick tests, and sIgE levels.

RECENT FINDINGS

Baking, boiling, canning, fermenting, pasteurizing, peeling, powdering, and roasting heterogenously impact the likelihood of reactivity in egg-, milk-, peanut- and other legume-, tree nut-, fruit-, and seafood-allergic patients. These variations may be due to the use of different temperatures, duration of processing, presence of a matrix, and the specific allergens involved, among other factors. Accurate prediction of tolerance to processed allergens with skin prick tests and sIgE levels remains largely elusive. Food allergy management strategies, especially with milk and egg, have capitalized on the decreased allergenicity of baking. Many milk- and egg-allergic patients tolerate baked and heated forms of these allergens, and the use of these processed foods in oral immunotherapy (OIT) continues to be extensively investigated. Heat is also well recognized to reduce allergic symptoms from some fruits and vegetables in food-pollen syndrome. Other forms of processing such as boiling, fermenting, and canning can reduce allergenicity to a diverse array of foods. Roasting, on the other hand, may increase allergenicity. The application of food processing to food allergy treatments remains largely unexplored by large clinical studies and provides a key avenue for future research. The recognition that food allergy represents a spectrum of hypersensitivity, rather than an all-or-nothing phenomenon, has led to approaches to enable dietary liberation with processed, less-allergenic foods and their use in food allergy immunotherapies.

A Panoramic Review on the Management of Rheumatoid Arthritis through Herbalism

Arthritis is a chronic inflammatory condition that affects millions of individuals worldwide. The conventional treatment options for arthritis often come with limitations and potential side effects, leading to increased interest in herbal plants as alternative therapies. This article provides a comprehensive overview of the use of herbal plants in arthritis treatment, focusing on their traditional remedies, active components, mechanisms of action, and pharmaceutical approaches for enhancing their delivery. Various herbal plants, including turmeric, ginger, Boswellia, and willow bark, have shown anti-inflammatory and analgesic properties, making them valuable options for managing arthritis symptoms. The active components of these herbal plants, such as curcumin, gingerols, and boswellic acids, contribute to their therapeutic effects. To enhance the delivery of herbal medicines, pharmaceutical approaches like nanoparticle-based drug delivery systems, liposomes, polymeric nanoparticles, nanoemulsions, microneedles, and inhalation systems have been explored. These approaches aim to improve bioavailability, targeted delivery, and controlled release of herbal compounds. Safety considerations, including potential interactions with medications and the risk of allergic reactions, are also discussed. Future perspectives for this field involve conducting well-designed clinical studies, enhancing standardization and quality control measures, exploring novel drug delivery systems, and fostering collaborations between traditional medicine practitioners and healthcare professionals. Continued research and development in these areas will help unlock the full potential of herbal plants in arthritis treatment, offering personalized and effective care for affected individuals.

Oral food challenge test results of patients with food allergy with specific IgE levels >100 UA/ml

Specific IgE level (sIgE) is an important factor indicating sensitization status in children with food allergies (FAs). The present study aimed to clarify oral food challenge test (OFC) results in children with FAs with sIgE levels ≥100 UA/ml compared with those in children with sIgE <100. The retrospective study analyzed patients who underwent OFC with egg white, cow milk and wheat at Gifu Prefectural general medical center, Gifu, Japan between July 2017 and March 2023. Clinical history, total IgE (tIgE), sIgE and correlation between sIgE, sIgE/tIgE and eliciting dose as the amount of intake protein were examined. In the <100 group, positive OFC showed significantly higher sIgE for egg white, ovomucoid and casein than negative OFC (P<0.05); however, there was no significant difference between positive and negative OFC in the ≥100 group. In the <100 group, positive OFC showed significantly higher sIgE/tIgE for ovomucoid, milk and casein than negative OFC (P<0.05); however, there was no significant difference in sIgE/tIgE between positive and negative OFC in the ≥100 group. There was a significant negative correlation between eliciting dose and sIgE for egg white and wheat (P<0.05). For milk and wheat, there was no significant difference between ≥100 group and the <100 group with regard to positive rates in the OFC. Therefore, OFC may be safely performed by decreasing total challenge dose for the ≥100 group.

Tree Nut Allergy in Children-What Do We Know? -A Review

Food allergy represents a significant public health concern, with its prevalence increasing in recent decades. Tree nuts are among major allergenic foods, and allergies to them are frequently linked to severe and potentially life-threatening reactions. Data on the prevalence and natural history of tree nut allergy are limited. Primary nut allergy typically presents with rapid-onset IgE-mediated symptoms. Diagnosis can be confirmed by demonstrating a positive skin prick test (SPT), specific IgE (sIgE), or through an oral food challenge. Component-resolved diagnostics (CRD) can identify those with a high risk of anaphylaxis. The main management strategy involves avoiding the culprit allergen and treating symptoms after accidental exposure. New therapeutic options, such as sublingual immunotherapy, oral food immunotherapy, with or without omalizumab, and other monoclonal antibodies, are being investigated to modify tree nut allergy. Tree nut allergy is a lifelong disease with a low likelihood of resolution. The aim of this paper is to present the current data on the prevalence, diagnosis, natural history, and management options for tree nut allergy.

Time trends in the epidemiology of food allergy in England: an observational analysis of Clinical Practice Research Datalink data

BACKGROUND

Estimates for the prevalence of food allergy vary widely, with a paucity of data for adults. The aim of this analysis was to report trends in the incidence and prevalence of food allergy in England, using a national primary care dataset.

METHODS

We analysed data from Clinical Practice Research Datalink between 1998 and 2018, with linked data to relevant hospital encounters in England. The main outcomes were incidence and prevalence of food allergy, according to three definitions of food allergy: possible food allergy, probable food allergy, and probable food allergy with adrenaline autoinjectors prescription. We also evaluated the difference in proportion of patients prescribed adrenaline autoinjectors by English Index of Multiple Deprivation (IMD), age, and by previous food anaphylaxis, and explored differences in patient encounters (general practice vs emergency department setting).

FINDINGS

7 627 607 individuals in the dataset were eligible for inclusion, of whom 150 018 (median age 19 years [IQR 4-34]; 82 614 [55·1%] female and 67 404 [44·9%] male) had a possible food allergy. 121 706 met diagnostic criteria for probable food allergy, of whom 38 288 were prescribed adrenaline autoinjectors. Estimated incidence of probable food allergy doubled between 2008 and 2018, from 75·8 individuals per 100 000 person-years (95% CI 73·7-77·9) in 2008 to 159·5 (156·6-162·3) individuals per 100 000 person-years in 2018. Prevalence increased from 0·4% (23 399 of 6 432 383) to 1·1% (82 262 of 7 627 607) over the same period and was highest in children under 5 years (11 951 [4·0%] of 296 406 in 2018) with lower prevalence in school-aged children (from 11 353 [2·4%] of 473 597 in 2018 for children aged 5-9 years to 6896 [1·7%] of 404 525 for those aged 15-19 years) and adults (42 848 [0·7%] of 5 992 454 in 2018). In those with previous food anaphylaxis, only 2321 (58·3%) of 3980 (975 [64·0%] of 1524 children and young people and 1346 [54·8%] of 2456 adults) had a prescription for adrenaline autoinjector. Adrenaline autoinjectors prescription was less common in those resident in more deprived areas (according to IMD). In the analysis of health-care encounters, 488 604 (97·1%) of 503 198 visits recorded for food allergy occurred in primary care, with 115 655 (88·4%) of 130 832 patients managed exclusively in primary care.

INTERPRETATION

These estimates indicate an important and increasing burden of food allergy in England. Our findings that most patients with food allergy are managed outside the hospital system, with low rates of adrenaline autoinjector prescription in those with previous anaphylaxis, highlight a need to better support those working in primary care to ensure optimal management of patients with food allergy.

FUNDING

UK Food Standards Agency and UK Medical Research Council.

Clinical-Hematological Changes and Predictors of Severity in Acute Food Protein-Induced Enterocolitis Syndrome Reactions at Oral Food Challenge: A Multicenter Observational Study

BACKGROUND

Oral food challenge (OFC) is the criterion standard for diagnosis of acute food protein-induced enterocolitis syndrome (FPIES). No diagnostic/prognostic biomarkers are available, and OFC assessment criteria are not validated.

OBJECTIVE

To assess clinical-hematological changes and predictors of severity of FPIES reactions at OFC.

METHODS

This was an observational multicenter prospective study. Children aged 0 to 18 years diagnosed with acute FPIES were recruited at follow-up OFC in 12 tertiary centers in Spain and Italy. OFC outcomes (as positive/negative/inconclusive and mild/moderate/severe) were assessed on the basis of published "2017 FPIES Consensus" criteria. Clinical characteristics were recorded, and full blood cell count was done at baseline, reaction onset, and 4 hours later. Regression analysis was performed to assess predictors of severe reactions at OFC.

RESULTS

A total of 81 children had positive OFC (mild in 11% [9 of 81], moderate in 61% [49 of 81], and severe in 28% [23 of 81]). Increase in neutrophils and reduction in eosinophils, basophils, and lymphocytes were observed (P < .05). OFC was inconclusive in 19 cases despite objective signs or neutrophilia. Regression analysis showed that a 2-day OFC protocol where only 25% of an age-appropriate portion is given on day 1 (not sex, age, culprit food, cumulative dose, and previous reaction severity) was associated with reduced odds of severe reaction compared with giving multiple doses in a single day.

CONCLUSIONS

Distinct hematological changes may help support FPIES diagnosis. Current OFC assessment criteria may not capture the broad spectrum of acute FPIES presentations. This 2-day protocol may be associated with a reduced risk of severe reactions. Future work should aim to develop safer OFC and non-OFC diagnostics for FPIES.

Algae-derived compounds: Bioactivity, allergenicity and technologies enhancing their values

As a rapidly growing source of human nutrients, algae biosynthesize diverse metabolites which have promising bioactivities. However, the potential allergenicity of algal components hinder their widespread adoption. This review provides a comprehensive review of various macro and micronutrients derived from algal biomass, with particular focus on bioactive compounds, including peptides, polyphenols, carotenoids, omega-3 fatty acids and phycocyanins. The approaches used to produce algal bioactive compounds and their health benefits (antioxidant, antidiabetic, cardioprotective, anti-inflammatory and immunomodulatory) are summarised. This review particularly focuses on the state-of-the-art of precision fermentation, encapsulation, cold plasma, high-pressure processing, pulsed electric field, and subcritical water to reduce the allergenicity of algal compounds while increasing their bioactivity and bioavailability. By providing insights into current challenges of algae-derived compounds and opportunities for advancement, this review contributes to the ongoing discourse on maximizing their application potential in the food nutraceuticals, and pharmaceuticals industries.

World Allergy Organization (WAO) Diagnosis and Rationale for Action against Cow's Milk Allergy (DRACMA) guidelines update - XVI - Nutritional management of cow's milk allergy

Cow's milk allergy (CMA) is one of the most common presentations of food allergy in early childhood. Management of CMA involves individualized avoidance of cow's milk and other mammalian milk and foods containing these. Optimal elimination of cow's milk avoidance includes: label reading; information about safe and nutritious substitute foods; appropriate choice of infant formula or a plant-based food; establishing tolerance to baked milk and monitoring nutritional intake and growth. Substitute formulas are divided into soy formula (not hydrolyzed), milk-based extensively hydrolyzed formulas, rice based extensive, and partially hydrolyzed formulas and amino acid-based formulas. The use of other mammalian milks is not recommended for the management of cow's milk allergy due to a high level of cross-reactivity and nutritional concerns. For toddlers who are eating well, children, and adults, a suitable plant-based beverage may be a suitable alternative to a specialized formula, following careful nutritional considerations. Families need to be instructed on finding suitable nutritious foods and how to prepare suitable meals at home. Individuals with CMA also need to know how to identify and treat acute severe reactions.

Perspectives in the validation of DEFASE: a paradigm shift in food allergy management

PURPOSE OF REVIEW

To explore the groundbreaking international consensus on the DEFASE (DEfinition of Food Allergy Severity) project as a revolutionary grading system for IgE-mediated food allergy severity. Against the backdrop of the growing public health challenge posed by food allergy, this article delves into the importance of validating and implementing DEFASE in real-world clinical settings.

RECENT FINDINGS

With new therapeutic options available for food allergy, including biologics alongside immunotherapy, it is urgent to properly support clinical decision-making in the management of the disease. The DEFASE score is the first international consensus-based grading system of severity associated with food allergy as a whole disease embracing multidisciplinary perspectives from different stakeholders involved. In its current version, this comprehensive scoring system has been developed to be used in research settings.

SUMMARY

The review emphasizes the potential impact of DEFASE on patient outcomes, healthcare management, and resource allocation, underscoring its significance for the allergy scientific community. Future research should focus on internal and external validation of the scoring system, targeting these models to various food allergenic sources, populations, and settings.

Evaluation of clinical outcomes of efficacy in food allergen immunotherapy trials, COFAITH EAACI task force

Food allergy is a global public health problem that until recent years lacked any aetiological treatment supported by academy, industry and regulators. Food immunotherapy (AIT) is an evolving treatment option, supported by clinical practice and industry trial data. Recent AIT meta-analyses have highlighted the difficulty in pooling safety and efficacy data from AIT trials, due to secondary heterogeneity in the study. An EAACI task force (CO-FAITH) initiated by the Paediatric Section was created to focus on AIT efficacy outcomes for milk, egg and peanut allergy rather than in trial results. A systematic search and a narrative review of AIT controlled clinical trials and large case series was conducted. A total of 63 manuscripts met inclusion criteria, corresponding to 23, 21 and 22 studies of milk, egg and peanut AIT, respectively. The most common AIT efficacy outcome was desensitization, mostly defined as tolerating a maintenance phase dose, or reaching a particular dose upon successful exit oral food challenge (OFC). However, a large degree of heterogeneity was identified regarding the dose quantity defining this outcome. Sustained unresponsiveness and patient-reported outcomes (e.g. quality of life) were explored less frequently, and to date have been most rigorously described for peanut AIT versus other allergens. Change in allergen threshold assessed by OFC remains the most common efficacy measure, but OFC methods suffer from heterogeneity and methodological disparity. This review has identified multiple heterogeneous outcomes related to measuring the efficacy of AIT. Efforts to better standardize and harmonize which outcomes, and how to measure them must be carried out to help in the clinical development of safe and efficacious food allergy treatments.

Recognition of nuts and seeds in children with/without food allergies and their mothers: A reflection of culinary culture

BACKGROUND

Nuts and seeds are among the leading causes of food allergy. Effective food allergy management hinges on the ability to identify and avoid relevant foods.

AIM

To evaluate the nut/seed recognition ability in both children and mothers.

METHODS

Primary caregivers (mothers) and their children (6-18 years old) with/without food allergies were shown photographs of nuts/seeds, and their products with visible/hidden allergens to assess their ability to recognize accurately.

RESULTS

A total of 196 children and 184 mothers participated. The median ages of the children and mothers were 7.6 (6.8-10) and 37.8 (33.1-41.5) years, respectively. Over 75% of the children/adolescents and over 90% of the mothers accurately identified the kernel forms of nuts/seeds, except pine nuts. Walnuts, hazelnuts, almonds, and cashews were the most accurately recognized kernel forms by both populations. Generally, the kernel forms were recognized 5-20% more accurately than their in-shell forms, followed by products with visible and hidden forms, respectively. Some Turkish culinary-specific products with visible/hidden allergens were recognized as frequently as the kernel/in-shell forms by both study groups. Although there was a similar recognition pattern between study groups and subgroups (nut/seed allergy, other food allergy, controls), higher rates of recognition were found in mothers than in their children and adolescents than in schoolchildren.

CONCLUSION

In Eastern Mediterranean region, nuts and sesame seeds are highly recognized by both mothers and their children. Accurate identification of these foods is likely a culinary feature, but not the result of increased awareness. More information is needed on whether this ability reduces the risk of exposure.

Improving fluorescence emission of cyproheptadine by hindering its intramolecular photoinduced electron transfer (PET): Application to content uniformity testing and human plasma

The ability to determine antihistaminic drugs in biological matrices is critical for the medication adherence assessment. Among these antihistaminic medications, cyproheptadine (CPD); that is acting as a potent first-generation antihistaminic drug that has been extensively prescribed for allergic patients. Most of the established approaches for CPD detection are not appropriate for this purpose owing to their weak sensitivity, lack of rapidity, and complicated experimental procedures. Herein, we present a very fast, highly sensitive, and reproducible approach for the detection of CPD in its pure form, tablet formulation, and spiked human plasma. The photoluminescence approach depends on hindering the intramolecular photoinduced electron transfer (PET) effect of the lone pair of the N-atom present on the piperidine ring of CPD by making the surrounding medium acidic using 1.0 M acetic acid. Based on blocking PET, the target CPD drug has been sensitively detected from 5.0 to 500 ng mL-1 with a very low detection and quantitation limit of 7.01 and 21.25 ng mL-1, respectively. Moreover, the established approach was used for checking the tablet content uniformity testing for each tablet and spiked human plasma, and noteworthy, the matrices interference was insignificant.

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.

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.

A case-control study for comorbidity and laboratory factors associated with food-induced anaphylaxis

Background: Food-induced anaphylaxis (FIA) is a serious and potentially life-threatening allergic reaction triggered by food allergens. Objective: This case-control study aimed to investigate comorbidities and laboratory factors associated with FIA in the pediatric population of Israel. Methods: Retrospective data from the electronic health records of Leumit Health Care Services were used to identify 711 pediatric patients with FIA and 2560 subjects with food allergy and without anaphylaxis matched for age, gender, and ethnicity. Comorbidities were identified based on medical billing diagnosis codes, and laboratory characteristics were compared between the two groups. Results: The mean ± standard deviation age of patients with FIA was 4.1 ± 4.1 years, and 37.3% were girls. Laboratory analysis revealed increased eosinophil counts (p < 0.001), elevated immunoglobulin E (IgE) (p < 0.001), and IgA levels (p = 0.001) in the FIA group compared with the controls. With regard to comorbidities, the FIA group had higher prevalence rates of allergic diseases, including allergic rhinitis (odds ratio [OR] 1.72; p < 0.001), allergic conjunctivitis (OR 1.84; p = 0.001), asthma (OR 1.36; p < 0.001), angioedema (OR 6.37; p < 0.001), atopic dermatitis (OR 1.77; p < 0.001), and contact dermatitis (OR 1.42; p = 0.001). There was a trend toward significance for chronic spontaneous urticaria (p = 0.051). There was a significant negative association between helminthiases, particularly enterobiasis, and FIA (OR 0.76 [95% confidence interval, 0.59-0.98]; p = 0.029). Conclusion: This study provides valuable epidemiologic evidence on the associations among FIA, comorbidities, and laboratory factors in the pediatric population.

Asthma and food allergy: A nuanced relationship

Asthma is one of the most common chronic health conditions that affect children and adults. It is associated with many comorbid conditions, particularly those along the allergic spectrum, such as atopic dermatitis, allergic rhinitis, and food allergy. The relationship between asthma and food allergies involves prognosis, management, and understanding of risk for severe reactions. Both conditions are heterogeneous and can change over time, which necessitates an individualized approach toward counseling and management. Long-standing associations of an increased risk for food allergy fatality in individuals who have asthma is not as straightforward or concrete as previously believed. It is important for clinicians to have a current understanding of the evidence about the relationship between asthma and food allergy to participate in shared decision-making and counseling with patients. This review will offer background and new perspective surrounding the nuanced relationship of asthma and food allergy.

Severe food allergy reactions are associated with α-tryptase

BACKGROUND

Increased TPSAB1 copy numbers encoding ⍺-tryptase are associated with severe reactions in adults with Hymenoptera venom allergy, systemic mastocytosis, and idiopathic anaphylaxis.

OBJECTIVE

The primary objective was to assess the association between ⍺-tryptase and severity of food allergy.

METHODS

A total of 119 subjects underwent tryptase genotyping; 82 of them were from an observational food allergy cohort at the National Institute of Allergy and Infectious Disease (NIAID), and 37 were from a cohort of children who reacted to peanut oral food challenge (OFC) at Lurie Children's Hospital of Chicago. The primary predictor was presence or absence of ⍺-tryptase. The primary outcomes for both cohorts were measures of severity of food allergy reaction. Secondary outcomes included OFC symptom scores (Bock/Practical Allergy [PRACTALL] and Severity Grading Score for Acute Reactions [SGSAR]). Correlation between total α-tryptase isoforms and OFC scores was also assessed to account for gene dosage effects.

RESULTS

Among the subjects in the NIAID cohort, the presence of ⍺-tryptase was associated with a higher prevalence of food-triggered anaphylaxis than in those with only β-tryptase (P = .026). Similarly, only 1 of 6 subjects in the OFC cohort with only β-tryptase (17%) had a severe reaction, whereas 20 of 31 of subjects with α-tryptase (65%) had a severe reaction (P = .066). Subjects with ⍺-tryptase also had higher total SGSAR scores than did the subjects with no ⍺-tryptase (P = .003). In addition, there were also significant positive correlations between ⍺-tryptase isoform copy numbers and both higher total SGSAR and Bock/PRACTALL OFC scores (P = .008 and P = .003, respectively).

CONCLUSION

The presence of α-tryptase in subjects is correlated with a higher prevalence of anaphylaxis or severe reaction to food than in subjects without any α-tryptase.

Food allergy-A holistic approach to dietary management. A joint EAACI Research & Outreach Committee and INDANA review

Following a diagnosis of IgE-mediated food allergy, to secure the best outcome, the patient should receive individualized advice tailored to their specific needs, which considers the type and presentation of the food involved, level of exclusion required, risk of cross-contamination and any variance required for age, ethnicity, financial issues, and lifestyle. Issues such as food labels "may contain" statements, and variation in the threshold of reaction and impact of cofactors should also be considered. Most important is the need to ensure that the diagnosis is robust, especially given the nutritional, psychological, and socioeconomic issues that can affect an individual with a diagnosis of food allergy. Unnecessary exclusion of one or more foods that have not triggered allergic reactions, especially in individuals with allergic comorbidities, can result in severe IgE-mediated reactions on re-exposure. Given that food allergies may change over time, the diagnosis should be reviewed, to determine whether resolution is likely, or new-food triggers are reported. Regular assessment is vital, especially during childhood, to ensure reintroduction occurs at an appropriate time, thus enabling increased diversity of the diet and improvement in the quality of life. For some, an IgE-mediated food allergy may necessitate the life-long exclusion of foods, and for others, a food habitually eaten suddenly triggers an allergic reaction in adult life. People of all ages, ethnicities, and socioeconomic backgrounds deserve individual advice on the management of their food allergy to support a healthy diet and improve quality of life.

Preventing food allergy fatalities

Fatal anaphylaxis to food is thankfully rare, but every death is a potentially avoidable tragedy. Usually, there will be a coronial inquest to establish the 'how and why' for each death. Reviewing these food allergy-related deaths identifies a number of common themes and risk factors. While some are non-modifiable (such as age, gender and ethnicity), others are and include delayed epinephrine administration and communication difficulties in allergen avoidance. This review highlights the key messages in food allergy-related fatality prevention for healthcare professionals and patients alike, and where available, we explain the evidence behind such recommendations. We describe the data behind the good practice points to facilitate their adoption in routine practice without generating additional anxiety for what is a comparatively rare event. We also propose an information leaflet for patients and carers, developed with patients and endorsed by two major allergy charities, to facilitate dissemination of the recommendations in this review.

Contrast-induced anaphylaxis: does it occur in the medical environment and is it being responded to appropriately?

PURPOSE

To analyze the appropriateness of primary response for anaphylaxis due to iodinated contrast media (ICM) or gadolinium-based contrast agents (GBCA).

MATERIALS AND METHODS

This retrospective study included all patients in whom intravenous contrast agents (five types of ICMs and four types of GBCAs) were administered at our hospital between April 2016 and September 2021. For the patients who developed anaphylaxis, we obtained data on the time records of contrast injection, anaphylaxis onset, and intramuscular adrenaline (epinephrine) administration.

RESULTS

Of the 76,555 ICM and 30,731 GBCA administrations, anaphylaxis occurred in 49 cases (0.05%), and in 48 cases (98.0%) the onset was within 30 min after administration with widely distributed times (median, 7.5 min; interquartile range, 4.5-10.8 min; max, 26 min). Intramuscular adrenaline administration was performed in 43 cases (87.8%), and this was done within five minutes after the onset in 37 cases (75.5%). Only in 24 cases (49.0%), there were time records of both the onset and adrenaline administration (if performed).

CONCLUSION

Anaphylaxis occurred within 30 min after contrast injection in the majority of the cases, but times were widely distributed. Only in 75.5% of cases, appropriate primary treatment was performed, and the importance of keeping exact time records in patients' charts should be re-emphasized.

Mast Cells and Basophils in IgE-Independent Anaphylaxis

Anaphylaxis is a life-threatening or even fatal systemic hypersensitivity reaction. The incidence of anaphylaxis has risen at an alarming rate in the past decades in the majority of countries. Generally, the most common causes of severe or fatal anaphylaxis are medication, foods and Hymenoptera venoms. Anaphylactic reactions are characterized by the activation of mast cells and basophils and the release of mediators. These cells express a variety of receptors that enable them to respond to a wide range of stimulants. Most studies of anaphylaxis focus on IgE-dependent reactions. The mast cell has long been regarded as the main effector cell involved in IgE-mediated anaphylaxis. This paper reviews IgE-independent anaphylaxis, with special emphasis on mast cells, basophils, anaphylactic mediators, risk factors, triggers, and management.

Anaphylaxis management in a French pediatric emergency department: Lessons from the ANA-PED study

BACKGROUND

Anaphylaxis is a serious systemic hypersensitivity reaction that requires immediate recognition and prompt administration of epinephrine/adrenaline. The present study aimed to assess the appropriateness of epinephrine/adrenaline use in children identified as allergic by physicians in the emergency department (ED) at the time of the reaction, and to identify factors that are possibly associated with epinephrine/adrenaline administration, auto-injector prescription, and further referral to an allergist.

METHODS

We performed a retrospective cross-sectional study at the pediatric ED of the University Hospital of Montpellier, France. We included all consecutive children who attended the ED between 2016 and 2020 with an allergy-related diagnosis at discharge.

RESULTS

We included 1056 allergy-related visits, including 224 (21.2%) with a diagnosis of anaphylaxis at discharge; only 17.0% of them received an epinephrine/adrenaline injection, and 57.1% consulted an allergist after the acute episode. An auto-injector was prescribed to 63 (28.1%) patients at discharge from the ED. Besides the severity of the clinical presentation, factors associated with a guidelines-based management of the anaphylactic reaction and with an increased administration rate of epinephrine/adrenaline included presence of asthma symptoms and presence of extended skin reactions.

CONCLUSIONS

Our study underlines persistent gaps in the management of pediatric anaphylaxis in ED, focusing on hereby identified levers. By disseminating current knowledge and guidelines on anaphylaxis and allergies, specialists could work together with emergency physicians to establish effective management algorithms and improve anaphylaxis management and care pathways for children experiencing allergic reactions, especially anaphylaxis.

TRAIL REGISTRATION

Clinical Trials, number NCT05112367.

Comparison of recent anaphylaxis diagnostic criteria in real life: Can more patients be diagnosed as having anaphylaxis?

INTRODUCTION

In 2020, World Allergy Organization (WAO) updated their diagnostic criteria for anaphylaxis, which differed as a result from the National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) criteria which were still used in the 2021 update of the European Academy of Allergy and Clinical Immunology (EAACI) anaphylaxis guideline. Our aim was to evaluate and to compare both diagnostic criteria and attempt to identify factors affecting severity of anaphylaxis.

METHODS

The medical records of the patients who were evaluated with suspected anaphylaxis at 3 medical centers in Türkiye between 2014 and 2021, and underwent a detailed diagnostic work-up, were analyzed retrospectively. Diagnosis of anaphylaxis was evaluated based on the WAO 2020 and EAACI 2021 and NIAID/FAAN diagnostic criteria. The severity of anaphylaxis was determined according to the WAO systemic allergic reaction grading system. Grade 5 anaphylaxis was defined as having respiratory failure, collapse/hypotension, loss of consciousness. Patients' demographic and clinical characteristics were further analyzed depending on the severity of the reaction.

RESULTS

One thousand and six patients were evaluated and 232 patients without a convincing diagnosis of anaphylaxis were excluded from the study. The remaining 774 patients (70.6% female, median [Inter quartile range (IQR) 25-75] age: 42 [33-52]) were included for further examination. Anaphylaxis was diagnosed in 729 (94.2%) patients meeting both criteria whereas 35 patients (4.5%) with isolated laryngeal involvement and 10 (1.3%) patients with isolated respiratory involvement were only diagnosed according to the WAO 2020 criteria. Twenty-three patients (3.0%) had a diagnosis of indolent systemic mastocytosis. Mastocytosis was related to grade 5 anaphylaxis [p = 0.022, OR (CI) = 2.9 (1.1-7.6)]. Venom allergy was a risk factor for grade 5 anaphylaxis among those for whom an eliciting allergen could be determined [p = 0.03, OR (CI) = 2.7 (1.1-6.8)]. For drug induced anaphylaxis, parenteral route of drug administration and proton pump inhibitor (PPI) allergy were considered as risk factors for grade 5 anaphylaxis [p < 0.001, OR (CI) = 6.5 (2.5-17.0); p = 0.011, OR (CI) = 10.3 (1.6-63.3)].

CONCLUSION

This multicenter study demonstrated that both criteria identified the majority of patients with anaphylaxis, but the WAO 2020 diagnostic criteria identified an additional 6%. Hymenoptera stings, PPI allergy, parenteral drug administration, and underlying mastocytosis were associated with more severe episodes.

The future of food allergy: Challenging existing paradigms of clinical practice

The field of food allergy has seen tremendous change over the past 5-10 years with seminal studies redefining our approach to prevention and management and novel testing modalities in the horizon. Early introduction of allergenic foods is now recommended, challenging the previous paradigm of restrictive avoidance. The management of food allergy has shifted from a passive avoidance approach to active interventions that aim to provide protection from accidental exposures, decrease allergic reaction severity and improve the quality of life of food-allergic patients and their families. Additionally, novel diagnostic tools are making their way into clinical practice with the goal to reduce the need for food challenges and assist physicians in the-often complex-diagnostic process. With all the new developments and available choices for diagnosis, prevention and therapy, shared decision-making has become a key part of medical consultation, enabling patients to make the right choice for them, based on their values and preferences. Communication with patients has also become more complex over time, as patients are seeking advice online and through social media, but the information found online may be outdated, incorrect, or lacking in context. The role of the allergist has evolved to embrace all the above exciting developments and provide patients with the optimal care that fits their needs. In this review, we discuss recent developments as well as the evolution of the field of food allergy in the next decade.

Food-Induced Anaphylaxis: Data From the European Anaphylaxis Registry

BACKGROUND

Food is one of the most common elicitors of anaphylaxis, with an increasing incidence over recent years.

OBJECTIVES

To characterize elicitor-specific phenotypes and identify factors enhancing the risk or severity of food-induced anaphylaxis (FIA).

METHODS

We analyzed data from the European Anaphylaxis Registry applying an age- and sex-matched analysis of associations (Cramer's V) for single food triggers and calculated odds ratios (ORs) for severe FIA.

RESULTS

We identified 3,427 cases of confirmed FIA showing an age-dependent elicitor ranking (for children: peanut, cow's milk, cashew, and hen's egg; and for adults: wheat flour, shellfish, hazelnut, and soy). The age- and sex-matched analysis revealed defined symptom patterns for wheat and cashew. Wheat-induced anaphylaxis was more frequently associated with cardiovascular symptoms (75.7%; Cramer's V = 0.28) and cashew-induced anaphylaxis with gastrointestinal symptoms (73.9%; Cramer's V = 0.20). Furthermore, concomitant atopic dermatitis was slightly associated with anaphylaxis to hen's egg (Cramer's V = 0.19) and exercise was strongly associated with anaphylaxis to wheat (Cramer's V = 0.56). Additional factors influencing the severity were alcohol intake in wheat anaphylaxis (OR = 3.23; CI, 1.31-8.83) and exercise in peanut anaphylaxis (OR = 1.78; CI, 1.09-2.95).

CONCLUSIONS

Our data show that FIA is age-dependent. In adults, the range of elicitors inducing FIA is broader. For some elicitors, the severity of FIA seems to be related to the elicitor. These data require confirmation in future studies considering a clear differentiation between augmentation and risk factors in FIA.

Clinical features and risk factors of iodinated contrast media (ICM)-induced anaphylaxis

PURPOSE

To evaluate the clinical features and risk factors of iodinated contrast media (ICM)-induced anaphylaxis.

METHODS

This retrospective study included all patients undergoing contrast-enhanced computed tomography (CT) with intravenous ICM administration (iopamidol, iohexol, iomeprol, iopromide, ioversol) at our hospital between April 2016 and September 2021. Medical records of patients who experienced anaphylaxis were reviewed, and the multivariable regression model using generalized estimating equations was employed to eliminate the effect of intrapatient correlation.

RESULTS

Of the 76,194 ICM administrations (44,099 men [58 %] and 32,095 women; age, median, 68 years) to 27, 696 patients, anaphylaxis occurred in 45 cases in 45 different patients (0.06 % of administration and 0.16 % of patients), all with onset within 30 min after administration. Thirty-one (69 %) had no risk factors for ADRs, including 14 (31 %) who had previously used the same ICM that caused anaphylaxis. Thirty-one patients (69 %) had a history of ICM use without any ADRs. Four patients (8.9 %) received oral steroid premedication. The only factor associated with anaphylaxis was the type of ICM, with an odds ratio (OR) of 6.8 (p < 0.001) for iomeprol with iopamidol as a reference. No significant differences in OR of anaphylaxis were found for patients' age, sex, or premedication.

CONCLUSION

The overall incidence of anaphylaxis due to ICM was very low. More than half of the cases had no risk factors for ADRs and had no ADRs on past ICM administration, although the ICM type was associated with a higher OR.

The development of the DEFASE project

PURPOSE OF REVIEW

To familiarize the reader with the milestones of the DEFASE (Definition of Food Allergy Severity) project. This World Allergy Organization (WAO) initiative has recently developed the first international consensus-based classification system of severity associated with IgE-mediated food allergy as a whole disease incorporating multidisciplinary perspectives from different stakeholders involved.

RECENT FINDINGS

After a systematic review of current evidence on the definition of severity of food allergy, an e-Delphi methodology has been applied to obtain the consensus/agreement through repeated rounds of survey. This comprehensive scoring system has been developed to be used in research settings in its current version with the scope of stratifying the severity of a clinical situation of food allergy.

SUMMARY

Notwithstanding the limitations due to the complexity of the matter, the recent developed DEFASE definition will be relevant for establishing the levels of diagnostic, management and therapeutic commitment for the disease in the various geographical contexts. Future research should focus on internal and external validation of the scoring system, tailoring of these models to different food allergenic sources, populations, and settings.

Cofactors in food anaphylaxis in adults

Around 25% to 50% of food-induced allergic reactions in adults cause anaphylaxis, and epidemiologic evidence suggests that food is the most common cause of anaphylaxis. Reaction severity is unpredictable, and patients will often experience reactions of variable severity, even to an identical exposure (both dose and allergen). A common explanation for this phenomenon has been the impact of "cofactors"-factors that might contribute to reaction severity independent of the allergen exposure. Cofactors can influence reaction severity in 2 ways: either by reducing the reaction threshold (ie, the dose needed to trigger any symptoms) so that patients have no symptoms in the absence of the cofactor and only react with the cofactor present, or by increasing reaction severity such that individuals have only mild symptoms in the absence of the cofactor, but a more severe reaction when the cofactor is present. Indeed, the same patient may have reactions with different cofactors or even need more than one cofactor to develop a severe reaction. Cofactors reportedly play a role in approximately 30% of anaphylaxis reactions in adults. Exercise, nonsteroidal, anti-inflammatory drugs, alcohol, and sleep deprivation are the most frequent cofactors reported. Routine evaluation of the possible involvement of cofactors is essential in managing patients with food anaphylaxis: in patients with a suggestive history but a negative oral food challenge, cofactors should be taken into account to provide appropriate advice to reduce the risk of future anaphylaxis.

Will Oral Food Challenges Still Be Part of Allergy Care in 10 Years' Time?

Oral food challenges (OFCs) are currently the definitive diagnostic procedure in food allergy. Their design has evolved over the decades to maximize safety, optimize convenience, and address several specific clinical questions. However, they are a resource-intensive investigation that carry a risk for severe allergic reaction in which fatal outcomes, although rare, have been reported. In this review, we explore the many roles that OFC fulfil in the clinical and research settings. We also discuss progress that has been made in developing alternative diagnostic tools and how far these have reached in offering a viable replacement to OFC in clinical practice. Finally, we discuss the ongoing importance of research OFC to improve the future diagnostic capabilities of novel diagnostic tools.

Who Needs Epinephrine? Anaphylaxis, Autoinjectors, and Parachutes

International guidelines stipulate that intramuscular (IM) epinephrine (adrenaline) is the first-line treatment for anaphylaxis, with an established good safety profile. The availability of epinephrine autoinjectors (EAI) has greatly facilitated the lay administration of IM epinephrine in community settings. However, key areas of uncertainty remain around epinephrine usage. These include variations in prescribing EAI, what symptoms should prompt epinephrine administration, whether emergency medical services (EMS) need to be contacted after administration, and whether epinephrine administered via EAI reduces mortality from anaphylaxis or improves quality of life measures. We provide a balanced commentary on these issues. There is increasing recognition that a poor response to epinephrine, particularly after 2 doses, is a useful marker of severity and the need for urgent escalation. It is likely that patients who respond to a single epinephrine dose do not require EMS activation or emergency department transfer, but data are needed to demonstrate the safety of this approach. Lastly, patients at risk of anaphylaxis must be counseled against over-reliance on EAI alone.

Food hypersensitivity: an examination of factors influencing symptoms and temporal changes in the prevalence of sensitization in an adult sample

BACKGROUND/OBJECTIVES

Food hypersensitivity (FHS) is common, but little is known about the factors associated with severe reactions, age of onset and whether sensitization persists. This study examines the factors associated with self-reported severe food reactions, onset age and the changes in prevalence of sensitization to foods over time in an adult sample.

SUBJECTS/METHODS

We used data from adults taking part in the European Community Respiratory Health Survey (ECRHS) III (2010-2014) who provided information on food hypersensitivity, including symptoms, suspected culprit food and onset age (n = 4865). A subsample from six countries had serum food-specific IgE tested for 25 core foods and also in 10 years earlier (ECRHS II). We applied logistic regression and McNemar's test for analyses.

RESULTS

The prevalence of self-reported FHS was 13.5% at ECRHS III. Of those providing information on symptoms (n = 611), 26.4% reported severe reactions. About 80% of 1033 reported food-specific reactions (reported by 596 participants) began after age 15. History of asthma (odds ratio OR 2.12 95% confidence interval CI 1.13-3.44) and a younger age of onset of FHS (OR 1.02, 95% CI 1.01-1.03, per year) were associated with higher risks of a lifetime experience of severe food reactions. In the subsample with IgE tested in both surveys (n = 1612), the overall prevalence of sensitization to foods did not change over 10 years.

CONCLUSION

Our findings support previous observations of more severe food reactions in people with asthma and that most FHS reported by this sample started after age 15. We found no evidence of changes in the prevalence of sensitization to food in adults followed for 10 years.

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.

Efficacy and safety of food allergy oral immunotherapy in adults

BACKGROUND

Oral immunotherapy (OIT) is an emerging method for treating food allergy in children. However, data regarding adults undergoing this process are lacking.

METHODS

We retrospectively analyzed the medical records of patients with food allergy aged ≥17 years who completed OIT treatment between April 2010 and December 2020 at Shamir Medical Center. Data were compared with that of children aged 4 to <11 years and adolescents aged ≥11 to 17 treated during the same time period.

RESULTS

A total of 96 adults at a median age of 22.3 years who underwent OIT for milk (n = 53), peanut (n = 18), sesame (n = 7), egg (n = 5), and tree nuts (n = 13) were analyzed and compared with 1299 children and 309 adolescents. Adults experienced more adverse reactions requiring injectable epinephrine, both during in-clinic up-dosing (49% vs. 15.9% and 26.5% for children and adolescents, respectively, p < 0.0001) and during home treatment (22.9% vs. 12.4%, p = 0.007 for children, and 17.5%, p = 0.23 for adolescents). Most adults (61.5%) were fully desensitized, but the rates of full desensitization were significantly lower than children (73.4%, p = 0.013). Significantly more adults (28.3%) undergoing milk OIT failed treatment than children (14.3%, p = 0.015) and adolescents (14.1%, p = 0.022), while failure rates in adults undergoing OIT for other foods were low (9.3%) and comparable with children and adolescents.

CONCLUSIONS

OIT is successful in desensitizing most adults with IgE-mediated food allergy. Adults undergoing milk OIT are at increased risk for severe reactions and for OIT failure while failure rates in adults undergoing OIT for other foods are low.

Management of IgE-mediated food allergy in the 21st century

The 21st century has seen the propulsion of research in the field of food allergy, which has driven real changes in the clinical approach. Allergen immunotherapy has been recommended for the active management of food allergy. Data have shown promising additional methods of treatment, including biologics. Efforts have been devoted to the risk stratification of food allergy and the standardization of the assessment of food-allergic severity. Alternative routes of administration of epinephrine are under investigation to minimize any mechanical issue and the fear of injections. Evidence-based guidelines have been published by the main international societies in the field of anaphylaxis and food allergy management and new updates are in preparation. In the coming years, treatment options that are currently in pre-clinical or early clinical evaluation will hopefully lead to safe and effective disease-modifying therapies for food allergy in clinical practice. The identification of reliable biomarkers and the standardization of definitions and measurement approaches, alongside a shared decision-making with patients and families, will be key for the development of personalized care and to help minimize the substantial burden of food allergy.

CD4+CD25+CD127loFOXP3+ cell in food allergy: Does it predict anaphylaxis?

BACKGROUND

Food allergy (FA), hence the incidence of food anaphylaxis, is a public health problem that has increased in recent years. There are still no biomarkers for patients with FA to predict severe allergic reactions such as anaphylaxis.

OBJECTIVE

There is limited information on whether regulatory T (Treg) cell levels are a biomarker that predicts clinical severity in cases presenting with FA, and which patients are at a greater risk for anaphylaxis.

METHODS

A total of 70 children were included in the study: 25 who had IgE-mediated cow's milk protein allergy (CMPA) and presented with non-anaphylactic symptoms (FA/A-), 16 who had IgE-mediated CMPA and presented with anaphylaxis (FA/A+) (a total of 41 FA cases), and a control group consisting of 29 children without FA. The study was conducted by performing CD4+CD25+CD127^loFOXP3+ cell flow cytometric analysis during resting at least 2 weeks after the elimination diet to FA subjects.

RESULTS

When the FA group was compared with healthy control subjects, CD4+CD25+CD127_loFOXP3+ cell rates were found to be significantly lower in the FA group (p < 0.001). When the FA/A- and FA/A+ groups and the control group were compared in terms of CD4+CD25+CD127^loFOXP3+ cell ratios, they were significantly lower in the FA/A- and FA/A+ groups compared to the control group (p < 0.001).

CONCLUSIONS

Although there was no significant difference between the FA/A+ group and the FA/A- group in terms of CD4+CD25+CD127^loFOXP3+ cells, our study is important, as it is the first pediatric study we know to investigate whether CD4+CD25+CD127^loFOXP3+ cells in FA predict anaphylaxis.

Perinatal exposure to foodborne inorganic nanoparticles: A role in the susceptibility to food allergy?

Food allergy (FA) is an inappropriate immune response against dietary antigens. Various environmental factors during perinatal life may alter the establishment of intestinal homeostasis, thereby predisposing individuals to the development of such immune-related diseases. Among these factors, recent studies have emphasized the chronic dietary exposure of the mother to foodborne inorganic nanoparticles (NP) such as nano-sized silicon dioxide (SiO2), titanium dioxide (TiO2) or silver (Ag). Indeed, there is growing evidence that these inorganic agents, used as food additives in various products, as processing aids during food manufacturing or in food contact materials, can cross the placental barrier and reach the developing fetus. Excretion in milk is also suggested, hence continuing to expose the neonate during a critical window of susceptibility. Due to their immunotoxical and biocidal properties, such exposure may disrupt the host-intestinal microbiota's beneficial exchanges and may interfere with intestinal barrier and gut-associated immune system development in fetuses then the neonates. The resulting dysregulated intestinal homeostasis in the infant may significantly impede the induction of oral tolerance, a crucial process of immune unresponsiveness to food antigens. The current review focuses on the possible impacts of perinatal exposure to foodborne NP during pregnancy and early life on the susceptibility to developing FA.

Effects of Exercise and Sleep Deprivation on Reaction Severity During Oral Peanut Challenge: A Randomized Controlled Trial

BACKGROUND

The severity of allergic reactions to foods can vary markedly. Little is known of variations in reaction severity within or between individuals or the effects of cofactors.

OBJECTIVE

We examined the effects of sleep deprivation and exercise and repeat challenges on the severity and patterns of allergic reactions to peanut.

METHODS

In a randomized crossover study, adults with peanut allergy underwent 3 open peanut challenges in random order: with exercise after each dose, with sleep deprivation preceding challenge, and with no intervention. The primary outcome was eliciting dose, reported elsewhere. Reaction severity was a secondary outcome, evaluated using a weighted log-transformed numerical severity score. Analyses estimated the difference in severity between nonintervention challenge and challenges with exercise or sleep deprivation, adjusting for challenge order and using the highest dose tolerated by each individual across all their challenges. Symptom pattern reproducibility was assessed by comparing symptom sequences using pairwise sequence alignment to obtain a percentage match in symptom pattern.

RESULTS

Eighty-one participants (mean age 25 y) completed at least 1 postbaseline challenge. Sleep deprivation, but not exercise, significantly increased severity score by 48% (95% CI 12%-84%; P = .009) compared with no intervention. A 38% increase in severity was observed between the first and the last postbaseline challenge (95% CI 1%-75%; P = .044). The average pairwise match of symptoms within individuals was 82.4% and across individuals was 78.3%.

CONCLUSIONS

A novel severity score demonstrates that sleep deprivation and repeated challenges increase reaction severity. Understanding factors affecting severity is essential for effective risk management. We also show that symptom patterns in repeat peanut challenges are similar within and between individuals.

Managing food allergy: GA2LEN guideline 2022

Food allergy affects approximately 2-4% of children and adults. This guideline provides recommendations for managing food allergy from the Global Allergy and Asthma European Network (GA2LEN). A multidisciplinary international Task Force developed the guideline using the Appraisal of Guidelines for Research and Evaluation (AGREE) II framework and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. We reviewed the latest available evidence as of April 2021 (161 studies) and created recommendations by balancing benefits, harms, feasibility, and patient and clinician experiences. We suggest that people diagnosed with food allergy avoid triggering allergens (low certainty evidence). We suggest that infants with cow's milk allergy who need a breastmilk alternative use either hypoallergenic extensively hydrolyzed cow's milk formula or an amino acid-based formula (moderate certainty). For selected children with peanut allergy, we recommend oral immunotherapy (high certainty), though epicutaneous immunotherapy might be considered depending on individual preferences and availability (moderate certainty). We suggest considering oral immunotherapy for children with persistent severe hen's egg or cow's milk allergy (moderate certainty). There are significant gaps in evidence about safety and effectiveness of the various strategies. Research is needed to determine the best approaches to education, how to predict the risk of severe reactions, whether immunotherapy is cost-effective and whether biological therapies are effective alone or combined with allergen immunotherapy.

Risk factors for severe reactions in food allergy: Rapid evidence review with meta-analysis

This rapid review summarizes the most up to date evidence about the risk factors for severe food-induced allergic reactions. We searched three bibliographic databases for studies published between January 2010 and August 2021. We included 88 studies and synthesized the evidence narratively, undertaking meta-analysis where appropriate. Significant uncertainties remain with respect to the prediction of severe reactions, both anaphylaxis and/or severe anaphylaxis refractory to treatment. Prior anaphylaxis, an asthma diagnosis, IgE sensitization or basophil activation tests are not good predictors. Some molecular allergology markers may be helpful. Hospital presentations for anaphylaxis are highest in young children, yet this age group appears at lower risk of severe outcomes. Risk of severe outcomes is greatest in adolescence and young adulthood, but the contribution of risk taking behaviour in contributing to severe outcomes is unclear. Evidence for an impact of cofactors on severity is lacking, although food-dependent exercise-induced anaphylaxis may be an exception. Some medications such as beta-blockers or ACE inhibitors may increase severity, but appear less important than age as a factor in life-threatening reactions. The relationship between dose of exposure and severity is unclear. Delays in symptom recognition and anaphylaxis treatment have been associated with more severe outcomes. An absence of prior anaphylaxis does not exclude its future risk.

Acute At-Home Management of Anaphylaxis: 911: What Is the Emergency?

The appropriate at-home management of anaphylaxis begins with patient education on recognition and treatment, especially when and how to use epinephrine. Delayed administration of epinephrine as well as having severe symptoms and needing multiple doses of epinephrine to treat symptoms are risk factors for biphasic anaphylaxis. The successful implementation of at-home management of anaphylaxis requires appropriate patient selection and an algorithmic approach that recommends activation of emergency medical services (EMS) when the patient does not adequately respond to at-home administration of epinephrine or there are extenuating patient-related circumstances. Fortunately, approximately 98% of anaphylactic episodes respond to 2 or fewer doses of epinephrine, the standard prescription used for epinephrine autoinjectors; fatal anaphylaxis is very rare, as low as 0.002 deaths/million person-years; and biphasic reactions are uncommon (∼5%), and only extremely rarely lethal. Thus, most common concerns leading to recommended EMS activation and emergency department visits after epinephrine administration are generally unsubstantiated. Furthermore, emergency department visits do not always lead to better treatment and drive health care costs higher. Open communications with patients and families regarding risks and benefits of at-home management and observation versus EMS activation and emergency department evaluation after epinephrine administration for anaphylaxis are essential. However, we believe the data indicate that it is time to reconsider the often used and taught approach that recommends EMS activation whenever epinephrine is used.

Anaphylaxis in Chinese Children: Different Clinical Profile Between Children with and without a History of Asthma/Recurrent Wheezing

Purpose

Asthma and recurrent wheezing (RW) have been identified as risk factors for anaphylaxis; however, little is known about the characteristics of anaphylaxis in children with a history of asthma or RW in Chinese children.

Patients and Methods

This was a retrospective, observational chart review of children who were diagnosed with anaphylaxis in a tertiary children's hospital between 2014 and 2021. Patients' demographics, symptoms, triggers and presence of physician-diagnosed asthma/RW history were collected from medical charts.

Results

A total of 399 anaphylactic reactions in 264 patients were analyzed; 119 patients (45.1%) had a history of asthma/RW. Food was the most common cause (85.5%, 341/399). Compared with patients without a history of asthma/RW, buckwheat-induced anaphylaxis was significantly more common in the asthma/RW group (9.4% vs 0.5%, p < 0.001), patients with a history of asthma/RW had higher rates of oropharyngeal symptoms (17.3% vs 8.6%, p = 0.011) and wheezing (34.5% vs 15.9%, p < 0.001). Ninety-one reactions (22.8%, 91/399) presented as severe anaphylaxis, but no difference existed between asthma/RW and non-asthma/RW groups. Children with a history of asthma/RW were more likely to receive inhaled β agonists than children without a history of asthma/RW (11.8% vs 2.5%, p = 0.003). A larger proportion of children without asthma/RW history were treated with epinephrine (11.7%) than children with asthma/RW history (6.9%).

Conclusion

Our finding revealed that different clinical profiles of anaphylaxis in children with and without a history of asthma/RW. Our study did not find that children with a history of asthma/RW have more severe anaphylactic reactions compared with children without asthma/RW. Buckwheat-induced anaphylaxis was more common in the asthma/RW group, wheezing and oropharyngeal symptoms affected a higher proportion of the asthma/RW group.

Diversities of allergic pathologies and their modifiers: Report from the second DGAKI-JSA meeting

In October 2021, researchers from the German Society of Allergy and Clinical Immunology (DGAKI) and from the Japanese Society of Allergology (JSA) focused their attention on the pathological conditions and modifiers of various allergic diseases. Topics included 1) the pathophysiology of IgE/mast cell-mediated allergic diseases; 2) the diagnosis and prevention of IgE/mast cell-mediated diseases; 3) the pathophysiology, diagnosis, and treatment of eosinophilic airway diseases; and 4) host-pathogen interaction and allergic diseases. This report summarizes the panel discussions, which highlighted the importance of recognizing the diversity of genetics, immunological mechanisms, and modifying factors underlying allergic diseases.