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Treating food allergy

Declaration of sponsorship Novartis Pharma AG
Read time: 35 mins
Last updated:8th Nov 2022
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
In this section

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 ingestions23. Currently, in the European guidelines, oral immunotherapy (OIT) can be recommended for the treatment of milk, egg, and peanut allergies24.

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 studied25.

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References

  1. Muraro A, Werfel T, Hoffmann-Sommergruber K, Roberts G, Beyer K, Bindslev-Jensen C, et al. EAACI Food Allergy and Anaphylaxis Guidelines: Diagnosis and management of food allergy. Allergy Eur J Allergy Clin Immunol. 2014;69(8):1008–1025.
  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.
  7. Hill DA, Dudley JW, Spergel JM. The Prevalence of Eosinophilic Esophagitis in Pediatric Patients with IgE-Mediated Food Allergy. J Allergy Clin Immunol Pract. 2017;5(2):369–375.
  8. Petroni D, Spergel JM. Eosinophilic esophagitis and symptoms possibly related to eosinophilic esophagitis in oral immunotherapy. Ann Allergy, Asthma Immunol. 2018;120(3):237-240.e4.
  9. Wright BL, Fernandez-Becker NQ, Kambham N, Purington N, Cao S, Tupa D, et al. Gastrointestinal Eosinophil Responses in a Longitudinal, Randomized Trial of Peanut Oral Immunotherapy. Clin Gastroenterol Hepatol. 2021;19(6):1151-1159.e14.
  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.
  11. Muraro A, Werfel T, Hoffmann-Sommergruber K, Roberts G, Beyer K, Bindslev-Jensen C, et al. EAACI Food Allergy and Anaphylaxis Guidelines: Diagnosis and management of food allergy. Allergy Eur J Allergy Clin Immunol. 2014;69(8):1008–1025.
  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.
  14. Mayorga C, Palomares F, Cañas JA, Pérez-Sánchez N, Núñez R, Torres MJ, et al. New Insights in Therapy for Food Allergy. Foods. 2021;10(5):1037.
  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, Tseng A, Raji B, Ayis S, Peacock J, et al. Randomized Trial of Introduction of Allergenic Foods in Breast-Fed Infants. New England Journal of Medicine. 2016;374(18):1733-1743.
  17. 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. Journal of Allergy and Clinical Immunology. 2019;144(6):1606-1614.e1602.
  18. Lack G. Early exposure hypothesis: where are we now? Clinical and Translational Allergy. 2011;1(1):S71.b
  19. Lack G. Epidemiologic risks for food allergy. J Allergy Clin Immunol. 2008;121(6):1331-1336.
  20. Khaleva E, Vazquez-Ortiz M, Comberiati P, Dunngalvin A, Pite H, Blumchen K, et al. Current transition management of adolescents and young adults with allergy and asthma: A European survey. Clin Transl Allergy. 2020;10(1):1–15.
  21. Christie D, Viner R. Adolescent development. 2005;330(7486):301.
  22. Vazquez-Ortiz M, Angier E, Blumchen K, Comberiati P, Duca B, DunnGalvin A, et al. Understanding the challenges faced by adolescents and young adults with allergic conditions: A systematic review. Allergy Eur J Allergy Clin Immunol. 2020;75(8):1849–1879.
  23. 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.
  24. Pajno GB, Fernandez-Rivas M, Arasi S, Roberts G, Akdis CA, Alvaro-Lozano M, et al. EAACI Guidelines on allergen immunotherapy: IgE-mediated food allergy. Allergy Eur J Allergy Clin Immunol. 2018;73(4):799–815.
  25. Macdougall JD, Burks AW, Kim EH. Current Insights into Immunotherapy Approaches for Food Allergy. ImmunoTargets Ther. 2021;Volume 10:1–8.
  26. S. Food and Drug Administration (USFDA). Palforzia Highlights of prescribing information. 2020. https://www.fda.gov/media/134838/download. Accessed 6 July 2021.
  27. European Medicines Agency (EMA). Palforzia - Summary of Product Characteristics (SmPC). https://www.ema.europa.eu/en/documents/product-information/palforzia-epar-product-information_en.pdf. Accessed 7 June 2021.
  28. Tsai M, Mukai K, Chinthrajah RS, Nadeau KC, Galli SJ. Sustained successful peanut oral immunotherapy associated with low basophil activation and peanut-specific IgE. J Allergy Clin Immunol. 2020;145(3):885-896.e6.
  29. 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.
  30. 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.
  31. Kim EH, Bird JA, Kulis M, Laubach S, Pons L, Shreffler W, et al. Sublingual immunotherapy for peanut allergy: Clinical and immunologic evidence of desensitization. J Allergy Clin Immunol. 2011;127(3):640-646.e1.
  32. Enrique E, Malek T, Pineda F, Palacios R, Bartra J, Tella R, et al. Sublingual immunotherapy for hazelnut food allergy: A follow-up study. Ann Allergy, Asthma Immunol. 2008;100(3):283–284.
  33. Enrique E, Pineda F, Malek T, Bartra J, Basagaña M, Tella R, et al. Sublingual immunotherapy for hazelnut food allergy: A randomized, double-blind, placebo-controlled study with a standardized hazelnut extract. J Allergy Clin Immunol. 2005;116(5):1073–1079.
  34. 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.
  35. Chu DK, Wood RA, French S, Fiocchi A, Jordana M, Waserman S, et al. Oral immunotherapy for peanut allergy (PACE): a systematic review and meta-analysis of efficacy and safety. Lancet. 2019;393(10187):2222–2232.
  36. Cianferoni A. Eosinophilic esophagitis as a side effect of food oral immunotherapy. Med. 2020;56(11):1–12.
  37. Anagnostou A. A practical, stepwise approach to peanut oral immunotherapy in clinical practice: benefits and risks. J Asthma Allergy. 2021;14:277–285.
  38. Nachshon L, Goldberg MR, Katz Y, Levy MB, Elizur A. Long-term outcome of peanut oral immunotherapy—Real-life experience. Pediatr Allergy Immunol. 2018;29(5):519–526.
  39. Feng C, Kim JH. Beyond Avoidance: the Psychosocial Impact of Food Allergies. Clin Rev Allergy Immunol. 2019;57(1):74–82.

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