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Food Allergy Learning Zone
Declaration of sponsorship Novartis Pharma AG

Treating food allergy

Declaration of sponsorship Novartis Pharma AG
Read time: 35 mins
Last updated:4th Aug 2021
Published:4th Aug 2021

There is no cure for food allergy. Get to know the management and treatment of this burdensome condition and examine:

  • The optimal approach to food allergy management in our interview with Dr Sharon Chinthrajah
  • Pharmacologic treatment options, including oral, epicutaneous, and sublingual immunotherapy
  • The limitations of current management strategies for food allergy

Food allergy management

Current guidance for the management of food allergy can be broadly divided into long-term strategies for avoiding the risk of reactions and short-term interventions for the rapid treatment of acute allergic reactions following accidental exposure1,2.

Gain a deeper understanding of the management of food allergy with Professor Sharon Chinthrajah below, including the teams involved in allergy care, the importance of education, and oral immunotherapy (OIT).

What is the multidisciplinary approach to treating food allergy?

The optimal approach to food allergy management is multidisciplinary and multifaceted, providing care for the range of comorbid conditions associated with food allergy as well as guidance and education for patients and their carers (Figure 1)3. Care should be guided by a range of healthcare professionals, including3:

  • General practitioners
  • Allergists
  • Dieticians
  • Nurses
  • Pharmacists
  • Psychologists
  • Dermatologists
  • Pulmonologists

A close collaboration between gastroenterologists and allergists is also useful for the management of gastrointestinal (GI) abnormalities associated with food allergy, such as eosinophilic esophagitis (EoE)4. Moreover, previous studies have shown that OIT induces concerning GI symptoms in 75–85% of patients5,6. There is also concern that OIT is inducing de novo EoE, which occurs in 2.7–4.7% of with IgE-mediated food allergy7,8. However, recent research indicates that transient eosinophilic inflammation can occur during OIT, but does not necessarily induce pathological EoE9.

T3 Food Allergy_Fig1.png

Figure 1. Current strategies for the management of food allergy10,11.

Food allergies can also have a huge psychosocial impact due to anxiety that can be faced when eating in social environments. Psychologists and therapists are therefore essential for addressing the impact on quality of life and psychological distress associated with food allergy12.

How do you provide education and dietary advice?

Dieticians play a key role in food allergy management by providing advice on allergen avoidance while also ensuring a balanced overall diet using replacement foods that replace all the nutrients required for a healthy diet. Trained in food allergy, they play a crucial role linking the clinical setting and community by guiding12:

  • Practical dietary management
  • How to read food labels
  • Avoidance of foods with practical advice
  • The substitution of foods
  • Regular food challenges to assess tolerance
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Pharmacological treatments and limitations

In the last decade, a significant number of clinical trials have investigated the use of potential immunotherapeutic options for food allergy that can induce desensitisation and reduce the frequency of allergic reactions after accidental ingestions20. Currently, in the European guidelines, oral immunotherapy (OIT) can be recommended for the treatment of milk, egg, and peanut allergies21.

What are the immunotherapy approaches to food allergy?

Food immunotherapy involves the incremental administration of specific allergens at fixed or increasing doses with the goal of increasing the clinical reaction threshold. Various types of strategies have been investigated including oral, epicutaneous, and sublingual. However, peanut oral immunotherapy has been the most extensively studied22.

What is oral immunotherapy (OIT)?

OIT involves the ingestion of food allergen protein to induce clinical desensitisation. While OIT for many allergens have been investigated, clinical trials have primarily focused on peanut allergy. This led to peanut allergen powder becoming the first approved treatment, by the U.S. Food and Drug Administration (FDA) and European Medicines Agency (EMA), for the prevention of severe reaction to peanuts in 4–17-year-olds23,24.

A notable recent study on OIT was the POISED study (N=120), a Phase 2 randomised control trial that evaluated the long-term sustained effects of peanut allergy OIT in adults and children5.

The POISED study revealed that, most patients could be successfully desensitised to 4000 mg of peanut protein, however, discontinuation or reduction of peanut OIT could increase the chance of regaining clinical reactivity in the majority5

Patients were maintained on 4000 mg peanut protein through to week 104 and then separated into three groups:

  • Peanut-0 group – discontinued peanut treatment
  • Peanut-300 group – ingested 300 mg peanut protein daily for 52 weeks
  • Placebo group – received oat flour

In the third year, using double-blind, placebo-controlled food challenges (DBPCFC) to 4000 mg peanut at three-month intervals up to one year, the primary outcome was met with 35% of the peanut-0 group and 4% of the placebo group passing the 4000 mg challenge at both 104 and 117 weeks (P=0.0024)5.

A significant difference between the Peanut-0 and Peanut-300 groups was observed with 13% of Peanut-0 versus 37% of Peanut-300 participants completing the 4000 mg DBPCFC 12 months after OIT discontinuation5.

The data in the POISED study highlighted that a discontinuation, or dose reduction, to 300 mg, of peanut protein could lead to an increased chance of regaining a clinical reactivity to larger doses5. BATs and specific IgEs at baseline were able to identify those patients who were more likely to be successful at week 11725.

Epicutaneous immunotherapy (EPIT)

EPIT requires placing an adhesive dermal patch, containing food protein, onto the skin to induce desensitisation through the passive transfer of solubilised protein via the skin26.

A phase 2 multi-centre study (N=74) found that peanut EPIT administration was safe and produced a modest treatment response after 52 weeks, with the highest responses among younger children (4–11 vs >11 years, P=0.03)26. Longer duration on therapy yielded larger tolerated doses on repeat challenges from the long term follow up of the Phase 3 study27.

Sublingual immunotherapy (SLIT)

SLIT involves using drops or tablets to place small quantities of the allergen under the tongue to induce desensitisation28.

Various studies have determined the safety and efficacy of SLIT in hazelnut29,30, peach31, and peanut. A double-blind, placebo-controlled study, of peanut SLIT showed that SLIT safely induced clinical desensitisation in peanut allergic children, with the treatment group safely ingesting 20 times more peanut protein than the placebo group (median 1710 mg vs 85 mg, P=0.011)28.

What are the limitations of current management strategies?

While avoidance strategies and the newly approved oral immunotherapy (OIT) are recommended for the treatment of food allergy1,2,21, it is important to consider their limitations when providing patient-centred care.

What are the limitations of allergen immunotherapy for food allergy?

While OIT is recommended in the European guidelines for the treatment of milk, egg, and peanut allergies21, and peanut allergen powder is now approved for the prevention of severe reaction to peanuts24, concerns have been raised about its safety32.

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References

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  2. Boyce JA, Assa’ad A, Burks AW, Jones SM, Sampson HA, Wood RA, et al. Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-sponsored expert panel. J Allergy Clin Immunol. 2010;126(6 SUPPL.):S1.
  3. Muraro A, Alejandro Mendoza Hernandez D. Managing food allergy and anaphylaxis: A new model for an integrated approach. 2019. doi:10.1016/j.alit.2019.10.004.
  4. Aceves SS. Food Allergy Testing in Eosinophilic Esophagitis: What the Gastroenterologist Needs to Know. Clin Gastroenterol Hepatol. 2014;12(8):1216–1223.
  5. Chinthrajah RS, Purington N, Andorf S, Long A, O’Laughlin KL, Lyu SC, et al. Sustained outcomes in oral immunotherapy for peanut allergy (POISED study): a large, randomised, double-blind, placebo-controlled, phase 2 study. Lancet. 2019;394(10207):1437–1449.
  6. The PALISADE Group of Clinical Investigators. AR101 Oral Immunotherapy for Peanut Allergy. N Engl J Med. 2018;379(21):1991–2001.
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  10. Cardona V, Ansotegui IJ, Ebisawa M, El-Gamal Y, Fernandez Rivas M, Fineman S, et al. World allergy organization anaphylaxis guidance 2020. World Allergy Organ J. 2020;13(10):100472.
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  12. Skypala IJ, De Jong NW, Angier E, Gardner J, Kull I, Ryan D, et al. Promoting and achieving excellence in the delivery of Integrated Allergy Care: The European Academy of Allergy & Clinical Immunology competencies for allied health professionals working in allergy. Clin Transl Allergy. 2018;8(1):1–6.
  13. Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol. 2018;141(1):41–58.
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  15. Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med. 2015;372(9):803–813.
  16. Perkin MR, Logan K, Bahnson HT, Marrs T, Radulovic S, Craven J, et al. Efficacy of the Enquiring About Tolerance (EAT) study among infants at high risk of developing food allergy. 2019. doi:10.1016/j.jaci.2019.06.045.
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  20. Worm M, Francuzik W, Dölle S, Lange L, Alexiou A. Current developments in the treatment of peanut allergy. Allergo J Int. 2021;30(2):56–63.
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  22. Macdougall JD, Burks AW, Kim EH. Current Insights into Immunotherapy Approaches for Food Allergy. ImmunoTargets Ther. 2021;Volume 10:1–8.
  23. U.S. Food and Drug Administration (USFDA). Palforzia Highlights of prescribing information. 2020. https://www.fda.gov/media/134838/download. Accessed 6 July 2021.
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  26. Jones SM, Sicherer SH, Burks AW, Leung DYM, Lindblad RW, Dawson P, et al. Epicutaneous immunotherapy for the treatment of peanut allergy in children and young adults. J Allergy Clin Immunol. 2017;139(4):1242-1252.e9.
  27. Fleischer DM, Shreffler WG, Campbell DE, Green TD, Anvari S, Assa’ad A, et al. Long-term, open-label extension study of the efficacy and safety of epicutaneous immunotherapy for peanut allergy in children: PEOPLE 3-year results. J Allergy Clin Immunol. 2020;146(4):863–874.
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  31. Fernández-Rivas M, Garrido Fernández S, Nadal JA, De Durana MDAD, García BE, González-Mancebo E, et al. Randomized double-blind, placebo-controlled trial of sublingual immunotherapy with a Pru p 3 quantified peach extract. Allergy Eur J Allergy Clin Immunol. 2009;64(6):876–883.
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  33. Cianferoni A. Eosinophilic esophagitis as a side effect of food oral immunotherapy. Med. 2020;56(11):1–12.
  34. Anagnostou A. A practical, stepwise approach to peanut oral immunotherapy in clinical practice: benefits and risks. J Asthma Allergy. 2021;14:277–285.
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