Omalizumab for the Treatment of Multiple Food Allergies

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

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

Epicutaneous immunotherapy for the treatment of peanut allergy

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

Anti-IgE and food allergy

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

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

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

Food allergy yardstick: Where does omalizumab fit?

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

Follicular T cells and the control of IgE responses

Atopy is considered the epidemic of the 21st century, and while decades of research have established a direct link between Th2 cells driving pathogenic IgE-mediated allergic disease, only in the past years have T follicular helper (Tfh) cells emerged as pivotal drivers of these responses. In this review, we will examine the molecular mechanisms governing the IgE response, with a particular emphasis on the key cytokines and signaling pathways. We will discuss the exclusion of IgE-producing B cells from germinal centers and explore the recently established role of follicular T cell function and heterogeneity in driving or curtailing these immune responses. Additionally, we will assess the current state of major monoclonal antibodies and allergen immunotherapies designed to counteract Th2-driven inflammation, as well as reflect on the need to investigate how these biologics impact Tfh cell activity, differentiation, and function, as these insights could pave the way for much-needed therapeutic innovation in the treatment of allergic diseases.

Addressing health disparities in food allergy: A Position Statement of the AAAAI Prior Authorization Task Force

Self-reported food allergies (FAs) affect approximately 8% of the US pediatric and approximately 10% of the adult population, which reflects potentially disproportionate increases among ethnically and racially minoritized groups. Multiple gaps and unmet needs exist regarding FA disparities. There is reported evidence of disparities in FA outcomes, and the FA burden may also be disproportionate in low-income families. Low family income has been associated with higher emergency care spending and insecure access to allergen-free food. Pharmacoinequity arises in part as a result of structural racism still experienced by historically marginalized populations today. Historically redlined communities continue to experience greater rates of neighborhood-level air pollution and indoor allergen exposure, lack of transportation to medical appointments, poverty, and lower prescription rates of necessary medications. Clinical research needs racially and ethnically diverse participation to ensure generalizability of research findings and equitable access to medical advances, but race reporting in clinical trials has been historically poor. Addressing health disparities in FA is a priority of clinical care, with professional organizations such as the American Academy of Allergy, Asthma & Immunology having a prominent role to play in mitigating the challenges faced by these individuals. In this position statement we recommend some key steps to address this important issue.

Community and academic allergists' perspectives on integrating biologics into food allergy care: A qualitative study

BACKGROUND

Biologics are an important area of research and development, including for treatment of food allergy (FA). However, how allergists perceive the risks and benefits of biologics to treat FA remains largely unknown.

OBJECTIVE

To explore how US-based allergists perceive the use of biologics in FA treatment.

METHODS

Using a combination of purposive and snowball sampling, providers were recruited through direct solicitation by email to participate in a telephone or Zoom interview about their perceptions of the risks and benefits of current and future FA treatment options. Interviews were transcribed, deidentified, and coded to conduct a thematic analysis.

RESULTS

We conducted 60 interviews with providers from 34 states working either in community practice (53.3%) or academic medical centers (46.7%). Our sample was primarily non-Hispanic White (60.0%) and men (56.7%). The plurality was in their 40s (41.7%). Our findings clustered in the following 4 main themes: (1) perceived benefits of biologics, (2) ideal use of biologics, (3) concerns about biologics, and (4) biologics as the perceived future of FA. Community and academic providers had largely similar views, but academic providers more often emphasized the benefits of biologics, and community providers were, on the whole, more supportive of using biologics as an adjunct to oral immunotherapy rather than as monotherapy.

CONCLUSION

This study indicates that providers hold mixed views about the use of biologics to treat FA. However, most were enthusiastic about prescribing biologics for FA while also being highly concerned about the cost to patients and the health care system.

EAACI guidelines on the management of IgE-mediated food allergy

This European Academy of Allergy and Clinical Immunology (EAACI) guideline provides recommendations for the management of IgE-mediated food allergy and was developed using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach. Following the confirmation of IgE-mediated food allergy diagnosis, allergen avoidance and dietary advice (with support of a specialised dietitian, if possible) together with the provision of a written treatment plan, education on the recognition of allergic symptoms and prescription of medication including adrenaline using an auto-injector are essential. Patients with significant anxiety and requirement for coping strategies may benefit from support from a clinical psychologist. As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg). Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care. Future research into disease modifying treatments for IgE-mediated food allergy are highly needed, with standardised and patient-focused protocols and outcomes.

Ara h 2-expressing cucumber mosaic virus-like particle (VLP Peanut) induces in vitro tolerogenic cellular responses in peanut-allergic individuals

BACKGROUND

Peanut allergy (PA) is one of the most prevalent food allergies with a lack of favorable safety/efficacy treatment. A cucumber mosaic virus-like particle expressing peanut allergen component Ara h 2 (VLP Peanut) has been developed as a novel therapeutic approach for PA.

OBJECTIVE

We assessed the tolerogenic properties and reactivity of VLP Peanut.

METHODS

Whole blood and peripheral blood mononuclear cells were collected from 6 peanut-allergic children. Modulation of dendritic cells (DCs), T cells, and B cells, stimulated with VLP Peanut, Ara h 2, and whole peanut extract in vitro, were assessed by quantitative real-time PCR and flow cytometry, respectively. Basophil and skin reactivity in response to VLP Peanut was assessed by basophil activation test and skin prick test, respectively.

RESULTS

VLP Peanut showed beneficial biochemical properties, fit for use in clinical studies. VLP Peanut induced IFN-γ+ TH1 (P < .05) while having reduced capacity to elicit proliferation of TH2, allergen-specific TH2, and IL-4+-T follicular helper cells. Moreover, VLP Peanut is associated with upregulation of DC1-associated genes (MX1) compared to Ara h 2 and whole peanut extract. VLP Peanut was the most prominent at inducing IL-10+ regulatory B cells (P < .05). Unbiased clustering analyses identified metaclusters of T and B cells targeted by VLP Peanut. Finally, VLP Peanut had reduced capacity to elicit high- and low-affinity IgE receptor-mediated responses compared to Ara h 2 or whole peanut extract (all P < .05). Finally, in an open-label first-in-human cohort of 6 peanut-allergic adults, administration of increasing concentration of VLP Peanut through skin prick test was tolerated and demonstrated no development of skin reactivity.

CONCLUSIONS

VLP Peanut displayed tolerogenic properties by modulating DCs, T cells, and B cells in vitro. Preliminary findings of skin reactivity using VLP Peanut in 6 peanut-allergic adults was safe and well tolerated in an open-label phase 1 study.

CLINICAL TRIAL IDENTIFIER

PROTECT, NCT05476497.

Immunoglobulin E (IgE)-mediated food allergy

Food allergy is defined as an adverse immunologic response to a food. Immunoglobulin E (IgE)-mediated reactions to foods are associated with a broad range of signs and symptoms that may involve any of the following body systems: the skin, gastrointestinal tract, respiratory tract, and cardiovascular system. IgE-mediated food allergy is a leading cause of anaphylaxis. Therefore, timely and appropriate diagnosis and treatment are imperative. A diagnosis of food allergy entails a careful history and diagnostic tests, which may include skin prick tests, serum-specific IgE, and oral food challenge. The goal of food allergy care is to empower patients and caregivers to manage the risk of food-allergic reactions, reduce food allergy-related anxiety, and achieve a sense of control over their condition. This can be achieved in different ways for different patients and across different life stages. This article provides an overview of the epidemiology, pathophysiology, diagnosis, and management of IgE-mediated food allergy.

Dust mite antigens endow dendritic cells with the capacity to induce a Th2 response by regulating their methylation profiles

BACKGROUND

It is well-known that Dendritic cells (DCs) are essential in the development of airway Th2 polarization and airway allergy (AA). The underlying mechanism is still not fully understood. The objective of this study is to examine the role of methyltransferase-like protein-5 (Mettl5), a methyltransferase involved in N6-methyladenosine (m6A) methylation, in altering DC's properties to facilitate the development of Th2 polarization and AA.

METHODS

Dust mite extracts (DME) were used as a specific antigen to establish an AA mouse model. The epigenetic status of DCs was examined using a Chromatin immunoprecipitation (ChIP) assay. A mouse strain carrying the Mettl5-deficient DCs was used to observe the role of Mettl5 in determining the phenotypes of DCs.

RESULTS

The results showed that the expression of Mettl5 was elevated in DCs, which was positively correlated with the AA response. The development of airway Th2 polarization was hindered by Mettl5 depletion in DCs. Mettl5 is involved in the transcription of the Timd4 gene in DCs caused by DME. The degradation of IRF5 by Mettl5 led to an increase in T cell immunoglobulin domain molecule-4 (TIM4) expression in DCs associated with DME. Inhibition of Mettl5 in DCs reconciled the DME-induced airway Th2 polarization and experimental AA.

CONCLUSIONS

Airway DCs from AA mice showed elevated amounts of Mettl5, which led to the expression of TIM4. The experimental AA was mitigated by Mettl5 inhibition.

From the bench to the clinic: basophils and type 2 epithelial cytokines of thymic stromal lymphopoietin and IL-33

Type 2 epithelial cytokines, including thymic stromal lymphopoietin and IL-33, play central roles in modulation of type 2 immune cells, such as basophils. Basophils are a small subset of granulocytes within the leukocyte population that predominantly exist in the blood. They have non-redundant roles in allergic inflammation in peripheral tissues such as the lung, skin and gut, where they increase and accumulate at inflammatory lesions and exclusively produce large amounts of IL-4, a type 2 cytokine. These inflammatory reactions are known to be, to some extent, phenocopies of infectious diseases of ticks and helminths. Recently, biologics related to both type 2 epithelial cytokines and basophils have been approved by the US Food and Drug Administration for treatment of allergic diseases. We summarised the roles of Type 2 epithelial cytokines and basophils in basic science to translational medicine, including recent findings.

Improving Adherence Through Collaboration and Care Coordination in the Management of Food Allergies and Asthma

Food allergies and asthma significantly impact individual health and global health care systems. Despite established management protocols for asthma and the emerging use of oral immunotherapy for food allergy, adherence to treatments remains a challenge for health care professionals and patients. This review explores the differences in adherence required of asthma and food-allergy treatments and strategies to improve adherence. We highlight the role of collaborative care coordination among health care professionals in enhancing adherence in asthma and food-allergy management and improving patient outcomes.

Probiotics as adjuvants to mitigate adverse reactions and enhance effectiveness in Food Allergy Immunotherapy

In the past decades, food allergies became increasingly dominant since early childhood, leading to a lower quality of life and to increasing costs addressed by the health care system. Beside standard avoidance of specific allergens and drug treatments following allergen exposure, a great deal of research has lately focused on Food Allergy Allergen Immunotherapy (FA-AIT). SCIT and EPIT (Subcutaneous and Epicutaneous Immunotherapy), OIT (Oral Immunotherapy), and SLIT (Sublingual Immunotherapy) consist in gradual exposure to allergens to desensitize and achieve tolerance once therapy has ended. Although promising, FA-AIT may bring acute local and systemic adverse reactions. To enhance efficacy, safety and convenience of AIT, the quest of potential adjuvants to mitigate the adverse reactions becomes crucial. Immunomodulatory activities, such as that of increasing the regulatory T cells and decreasing the IgE, have been observed in specific probiotics' strains and multiple studies elucidated the role of gut microbiota as a major interplayer among the host and its immune system. In this review, the microbiome modulation is shown as potential AIT adjuvant, nevertheless the need of more clinical studies in the near future is pivotal to assess the efficacy of targeted bacterial therapies and faecal microbiota transplantation.

Role of allergen immunotherapy and biologics in allergic diseases

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

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.

Monoclonal Antibody Switching in Biologic Treatment of Chronic Rhinosinusitis with Nasal Polyps

Objectives: to evaluate our real-world data on the efficacy and safety of switching between two monoclonal antibodies in biologic treatment of uncontrolled chronic rhinosinusitis with nasal polyps (CRSwNP). Methods: All patients receiving biologic treatment for uncontrolled CRSwNP between April 2020 and March 2024 at a tertiary referral center who needed transitioning between biologic agents were retrospectively analyzed. The following parameters were investigated: patient's clinical characteristics, wash-out periods, treatment outcome, and switching-related side effects. Results: Out of 91 CRSwNP patients who received biologic treatment, 4 patients (4.4%) necessitated switching to an alternative biologic agent. Three patients were switched to a different antibody because of insufficient symptom control with the initially prescribed biologic, while the other patient required switching to an alternative agent due to a side effect. Switching resulted in all four patients achieving a significant improvement in all outcome parameters. There were no switching-related side effects, and the switching procedure was performed in three cases without a wash-out period. Conclusion: CRSwNP patients under biologic therapy with an insufficient response or medication-related side effect may benefit from switching to an alternative biologic agent. Larger, prospective multicenter studies are warranted to further validate the effectiveness and safety of switching agents in the biologic treatment of CRSwNP.

Biologics in allergology and clinical immunology: Update on therapies for atopic diseases, urticaria, and angioedema and on safety aspects focusing on hypersensitivity reactions

The development of targeted therapies for atopic diseases, urticaria, and angioedema with biologics is progressing rapidly: New "targets" of clinical-therapeutic relevance have been identified, the corresponding targeted antibodies developed, tested in clinical trials, and approved for therapy. These include the anti-IgE antibody omalizumab (also effective and approved for the treatment of urticaria), the anti-IL-4/13 receptor-specific antibody dupilumab, the two anti-IL-13 antibodies lebrikizumab and tralokinumab, the anti-TSLP antibody tezepelumab, the two anti-IL-5 antibodies mepolizumab and reslizumab, and the anti-IL5 receptor-specific antibody benralizumab for the treatment of atopic diseases. For the treatment of hereditary angioedema, C1 inhibitor and the antibody lanadelumab (directed against kallikrein) have also long been approved as biologics in addition to low-molecular substances. Other therapeutic antibodies are in various stages of development. Furthermore, the range of indications for some very effective biologics has been successfully expanded to include additional diseases. In this context, the first results on biologic therapy of food allergy and eosinophilic esophagitis are interesting. Biologics that address different target structures are also increasingly being administered in combination, either simultaneously or sequentially, in order to achieve optimal efficacy. A developing area is the use of biologics in children and the observation of immunological and non-immunological side effects. In some cases, new unexpected side effects and hypersensitivity reactions have emerged, which in turn raise pathomechanistic questions, such as conjunctivitis with dupilumab therapy, which only appears to occur in the treatment of atopic dermatitis but not in the treatment of other atopic diseases. In dermatology, paradoxical reactions have been described under therapy with some biologics. And immune reactions of type alpha to epsilon to biologics (hypersensitivity reactions) continue to be a clinically relevant problem, whereby the selection of an alternative therapeutic agent is a challenge and the diagnostics that support this have not yet been sufficiently incorporated into routine work.

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

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

IgE versus IgG and IgA: Differential roles of allergen-specific antibodies in sensitization, tolerization, and treatment of allergies

The prevalence of asthma, rhinitis, and food allergies has increased dramatically over the last few decades. This increase originally started in western countries, but is now also evident in many other regions of the world. Given the fact that the increase is so quick, the noted increase cannot be linked to a genetic effect, and many environmental factors have been identified that are associated with increased or reduced prevalence of allergies, like changing dietary habits, increased urbanization, pollution, exposure to microorganisms and LPS, and the farming environment and raw milk consumption. Although the key role of allergen-specific IgE in allergies is well known, the role of allergen-specific IgG and IgA antibodies is less well defined. This review will provide an overview of the functions of allergen-specific IgE in allergy, the role of allergen-specific antibodies (IgG (4) and IgA) in allergen immunotherapy (AIT), the possibility to use allergen-specific antibodies for treatment of ongoing allergies, and the potential role of allergen-specific antibodies in tolerance induction to allergens in a preventive setting. In the last, more speculative, section we will present novel hypotheses on the potential role of allergen-specific non-IgE antibodies in allergies by directing antigen presentation, Th2 development, and innate immune training.

Omalizumab Implementation in Practice: Lessons Learned From the OUtMATCH Study

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

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

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

Prevalence and Characteristics of Accidental Ingestions Among Pediatric Food Allergy Patients

BACKGROUND

Despite a known diagnosis of food allergy, accidental ingestions continue to occur.

OBJECTIVE

To characterize accidental ingestions, including prevalence, risk factors, food allergen triggers, and severity of reactions.

METHODS

A prospective monthly survey developed by the Food Allergy Consortium at Northwestern University was administered to parents of food-allergic children between April 2015 and April 2017. The monthly survey included questions on any allergic reactions experienced in the previous month. In addition, chart reviews of 100 pediatric participants from Lurie Children's Hospital of Chicago allergy clinics (typical clinical encounters) were compared with the prospective survey results.

RESULTS

A total of 196 survey participants and 100 retrospective review subjects were analyzed-31.1% of participants from the surveyed cohort and 19.0% of participants from the retrospective review reported at least 1 accidental ingestion over 1 year. The rate of accidental ingestions reported in the prospective survey was high: 10% to 25% of participants each month reported an accidental ingestion, and multiple ingestions were common. Common triggers were milk, wheat, and tree nuts. In the retrospective cohort, the highest rate of accidental ingestion (25.0%) occurred for milk, followed by sesame (20.0%) and egg (18.8%). Rates of anaphylaxis after exposure were high in both the prospective and retrospective cohorts (33.1% and 16.7%, respectively).

CONCLUSIONS

Accidental ingestion rates were high among food-allergic patients. Multiple exposures, especially to milk, were common. Incidence of anaphylaxis was also high, suggesting that ongoing patient education on allergen avoidance and accidental exposure is imperative.

Biologics in Food Allergies: Emerging Therapies

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

Therapeutic monoclonal antibodies in allergy: Targeting IgE, cytokine, and alarmin pathways

The etiology of allergy is closely linked to type 2 inflammatory responses ultimately leading to the production of allergen-specific immunoglobulin E (IgE), a key driver of many allergic conditions. At a high level, initial allergen exposure disrupts epithelial integrity, triggering local inflammation via alarmins including IL-25, IL-33, and TSLP, which activate type 2 innate lymphoid cells as well as other immune cells to secrete type 2 cytokines IL-4, IL-5 and IL-13, promoting Th2 cell development and eosinophil recruitment. Th2 cell dependent B cell activation promotes the production of allergen-specific IgE, which stably binds to basophils and mast cells. Rapid degranulation of these cells upon allergen re-exposure leads to allergic symptoms. Recent advances in our understanding of the molecular and cellular mechanisms underlying allergic pathophysiology have significantly shaped the development of therapeutic intervention strategies. In this review, we highlight key therapeutic targets within the allergic cascade with a particular focus on past, current and future treatment approaches using monoclonal antibodies. Specific targeting of alarmins, type 2 cytokines and IgE has shown varying degrees of clinical benefit in different allergic indications including asthma, chronic spontaneous urticaria, atopic dermatitis, chronic rhinosinusitis with nasal polyps, food allergies and eosinophilic esophagitis. While multiple therapeutic antibodies have been approved for clinical use, scientists are still working on ways to improve on current treatment approaches. Here, we provide context to understand therapeutic targeting strategies and their limitations, discussing both knowledge gaps and promising future directions to enhancing clinical efficacy in allergic disease management.

[Efficacy of biologics for severe asthma on allergic comorbidities]

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

The use of biologics in food allergy management

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

The Relationship Between Asthma and Food Allergies in Children

Asthma and food allergy are two complex allergic diseases with an increasing prevalence in childhood. They share risk factors, including atopic family history, atopic dermatitis, allergen sensitization, and T2 inflammatory pathways. Several studies have shown that in children with a food allergy, the risk of developing asthma, particularly in early childhood, is high. Food allergen intake or the inhalation of aerosolized allergens can induce respiratory symptoms such as bronchospasm. Patients with both conditions have an increased risk of severe asthma exacerbations, hospitalization, and mortality. The current management of clinical food hypersensitivity primarily involves the dietary avoidance of food allergens and the use of self-injectable adrenaline for severe reactions. Poorly controlled asthma limits the prescription of oral immunotherapy to foods, which has emerged as an alternative therapy for managing food allergies. Biological therapies that are effective in severe asthma have been explored for treating food allergies. Omalizumab improves asthma control and, either alone or in combination with oral immunotherapy, increases the threshold of allergen tolerance. Understanding the interplay between asthma and food allergy is crucial for developing successful treatment approaches and ameliorating patient results.

Patient-Reported Outcome Measures in Food and Drug Allergy

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

The Role of Food Allergy in Atopic Dermatitis

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

Decisions With Patients, Not for Patients: Shared Decision-Making in Allergy and Immunology

Shared decision-making (SDM) is an increasingly implemented patient-centered approach to navigating patient preferences regarding diagnostic and treatment options and supported decision-making. This therapeutic approach prioritizes the patient's perspectives, considering current medical evidence to provide a balanced approach to clinical scenarios. In light of numerous recent guideline recommendations that are conditional in nature and are clinical scenarios defined by preference-sensitive care options, there is a tremendous opportunity for SDM and validated decision aids. Despite the expansion of the literature on SDM, formal acceptance among clinicians remains inconsistent. Surprisingly, a significant disparity exists between clinicians' self-reported adherence to SDM principles and patients' perceptions of its implementation during clinical encounters. This discrepancy underscores a fundamental issue in the delivery of health care, where clinicians may overestimate their integration of SDM, while patients' experiences suggest otherwise. This review critically examines the factors contributing to this inconsistency, including barriers within the health care system, clinician attitudes and behaviors, and patient expectations and preferences. By elucidating these factors in the fields of food allergy, asthma, eosinophilic esophagitis, and other allergic diseases, this review aims to provide insights into bridging the gap between clinician perception and patient experience in SDM. Addressing this discordance is crucial for advancing patient-centered care and ensuring that SDM is not merely a theoretical concept but a tangible reality in the.

Peanut Allergy in Children-Is Prevention Better than Cure?

Peanut allergy, one of the most frequently occurring allergies, usually starts in childhood and rarely subsides-often persisting throughout adult life. Accidental exposure to peanuts can often result in adverse reactions ranging from mild to life-threatening, such as anaphylactic shock. Historically, food avoidance and the use of rescue drugs have remained a fundamental management mechanism for dealing with food allergy. However, prevention of adverse reactions to food allergy is playing an increasing role. This is possible through the early introduction of peanuts into the diet, especially in infants at risk of this allergy. In recent years, specific immunotherapy has been used to develop desensitisation and, in some patients, tolerance-defined as a persistent state of clinical non-reactivity to the allergen after therapy is finished. The aim of this article is to summarise the current state of knowledge on the prevention and treatment of peanut allergy, with a focus on clinical trials, current guidelines, and recent experimental studies. This review may be particularly useful for paediatricians and general practitioners.

Transplant-Acquired Food Allergy in Children

BACKGROUND

Organ transplantation in children is a vital procedure for those with end-stage organ failure, but it has been linked to the development of post-transplant allergies, especially food allergies. This phenomenon, known as transplant-acquired food allergy (TAFA), is becoming increasingly recognized, though its mechanisms remain under investigation. Pediatric transplant recipients often require lifelong immunosuppressive therapy to prevent graft rejection, which can alter immune function and heighten the risk of allergic reactions. Our review aimed to gather the latest evidence on TAFA.

METHODS

We conducted a PubMed search from 25 June to 5 July 2024, using specific search terms, identifying 143 articles. After screening, 36 studies were included: 24 retrospective studies, 1 prospective study, 2 cross-sectional researches, and 9 case reports/series.

RESULTS

Most studies focused on liver transplants in children. The prevalence of food allergies ranged from 3.3% to 54.3%. Tacrolimus, alongside corticosteroids, was the most commonly used immunosuppressive therapy. In addition to food allergies, some patients developed atopic dermatitis, asthma, and rhinitis. Allergic symptoms typically emerged within a year post-transplant, with common allergens including milk, eggs, fish, nuts, soy, wheat, and shellfish. Both IgE-mediated and non-IgE-mediated reactions were observed, with treatment often involving the removal of offending foods and the use of adrenaline when necessary.

CONCLUSIONS

Consistent immunological monitoring, such as skin prick tests and IgE level assessments, is essential for early detection and management of allergies in these patients. Understanding the link between transplantation and allergy development is crucial for improving long-term outcomes for pediatric transplant recipients.

Does Comorbid Food Allergy Affect Response to Omalizumab in Patients with Asthma?

Background

The intrinsic link between food allergy and asthma is well-established, and comorbidity can exacerbate both conditions. Omalizumab, an anti-immunoglobulin E (IgE) antibody, has the biological plausibility to manage both conditions, but only a few small studies have assessed omalizumab in patients with comorbid asthma and food allergy.

Patients and Methods

We conducted a post hoc analysis of placebo-controlled, randomized clinical trials (IA05 in children and 008/009 in adolescents/adults) and real-world observational studies (EXCELS and PROSPERO). For each study, patients with asthma were stratified by whether they had physician-reported food allergy, as per baseline characteristics data.

Results

For patients with comorbid food allergy, there was evidence for increased atopy at baseline (numerically higher total IgE levels and atopic comorbidities). The collective body of evidence found that omalizumab consistently improved general and asthma-specific patient-centered outcomes (food allergy-specific outcomes were not available). For patients with asthma, omalizumab improved healthcare resource use (emergency room visits, hospitalizations, unscheduled doctor visits), quality of life (asthma-specific Asthma Quality of Life Questionnaire), productivity (missed work/school days and the Work Productivity and Activity Impairment: Asthma), and asthma outcomes (asthma exacerbations and Asthma Control Test score) regardless of comorbid food allergy.

Conclusion

There was no loss of omalizumab efficacy even though patients with both asthma and food allergy appeared to be generally more atopic. Omalizumab may be a viable management option for patients with these comorbidities.

Clinical trial registration

NCT00079937; NCT01922037; NCT00252135.

Maternal influences on offspring food allergy

The prevalence of allergies has been globally escalating. While allergies could appear at any age, they often develop in early life. However, the significant knowledge gap in the field is the mechanisms by which allergies affect certain people but not others. Investigating early factors and events in neonatal life that have a lasting impact on determining the susceptibilities of children to develop allergies is a significant area of the investigation as it promotes the understanding of neonatal immune system that mediates tolerance versus allergies. This review focuses on the research over the recent 10 years regarding the potential maternal factors that influence offspring allergies with a view to food allergy, a potentially life-threatening cause of anaphylaxis. The role of breast milk, maternal diet, maternal antibodies, and microbiota that have been suggested as key maternal factors regulating offspring allergies are discussed here. We also suggest future research area to expand our knowledge of maternal-offspring interactions on the pathogenesis of food allergy.

Insights into the clinical, immunologic, and genetic underpinnings of food allergy

The last few decades have seen striking changes in the field of food allergy. The prevalence of the disease has risen dramatically in many parts of the globe, and management of the condition has undergone major revision. While delayed introduction of common allergenic foods during infancy was advised for many years, the learning early about peanut allergy (LEAP) trial and other studies led to a major shift in infant feeding practices, with deliberate early introduction of these foods now recommended. Additionally, the Food and Drug Administration approved the first treatment for food allergy in 2020-a peanut oral immunotherapy (OIT) product that likely represents just the beginning of new immunotherapy-based and other treatments for food allergy. Our knowledge of the environmental and genetic factors contributing to the pathogenesis of food allergy has also undergone transformational advances. Here, we will discuss our efforts to improve the clinical care of patients with food allergy and our understanding of the immunological mechanisms contributing to this common disease.

The journey toward disease modification in cow milk protein allergy

Cow milk protein allergy (CMPA) is one of the most common food allergies in the pediatric age worldwide. Prevalence, persistence, and severity of this condition are on the rise, with a negative impact on the health-related quality of life of the patients and families and on the costs related to its management. Another relevant issue is that CMPA in early life may be the first stage of the "allergic march," leading to the occurrence of other atopic manifestations later in life, especially asthma, atopic eczema, urticaria, and rhinoconjunctivitis. Thus, "disease modification" options that are able to modulate the disease course of pediatric patients affected by CMPA would be very welcomed by affected families and healthcare systems. In this review, we report the most relevant progress on this topic.

Oral food immunotherapy in patients with atopic dermatitis

Atopic dermatitis (AD) is one of the main risk factors for infants in the development of food allergy. Oral immunotherapy (OIT) in early childhood has been found to be highly effective and safe in preschoolers with and without AD, especially in young infants. Delays in initiation of OIT in infants and children due to uncontrolled AD risk expansion of the number of foods children develop allergy to through unnecessary avoidance of multiple foods. Parents and caregivers may attribute eczema flares to OIT doses, which physicians usually ascribe to non-food triggers such as weather changes, psychological stress, and infection. There is a lack of published literature confirming OIT as a trigger of AD flares, and the degree to which OIT may be associated with AD flares needs to be further studied. We describe 8 case scenarios with varying degrees of AD flare before and during OIT. We propose management algorithms for children with preexisting concurrent AD and food allergy who are being considered for starting OIT and children with AD flares during OIT. Optimizing AD control strategies and providing adequate AD care education before starting OIT can reduce confusion for both parents and allergists if rashes arise during OIT, thus improving adherence to OIT.

Anaphylaxis in Practice: A Guide to the 2023 Practice Parameter Update

This review summarizes new research developments and clinical practice recommendations for the diagnosis and management of anaphylaxis presented in the Joint Task Force on Practice Parameters 2023 Anaphylaxis practice parameter Update. It is intended to serve as a high-level summary of the 2023 practice parameter, which makes clinically impactful recommendations based on evidence that has emerged since the 2015 practice parameter. We invite clinicians to explore the full 2023 practice parameter to understand the research methods and underlying evidence that have informed the recommendations summarized here. There are new and evolving diagnostic criteria for anaphylaxis, rules for defining elevated tryptase levels, and recognition of signs and symptoms particular to infants and toddlers. The administration of epinephrine should not be used as a surrogate to diagnose anaphylaxis. Risk factors for anaphylaxis should be assessed on a case-by-case basis. Patient counseling and shared decision-making are essential to support patients' treatment decisions and capacity to manage the risk of anaphylaxis at home and in other community settings. Activation of emergency medical services after home epinephrine administration may not be required in all cases, and patients should be engaged in shared decision-making to determine when home management may be appropriate.

Allergic Diseases and Mental Health

Neuropsychiatric symptoms have long been acknowledged as a common comorbidity for individuals with allergic diseases. The proposed mechanisms for this relationship vary by disease and patient population and may include neuroinflammation and/or the consequent social implications of disease symptoms and management. We review connections between mental health and allergic rhinitis, atopic dermatitis, asthma, vocal cord dysfunction, urticaria, and food allergy. Many uncertainties remain and warrant further research, particularly with regard to how medications interact with pathophysiologic mechanisms of allergic disease in the neuroimmune axis. Proactive screening for mental health challenges, using tools such as the Patient Health Questionnaire and Generalized Anxiety Disorder screening instruments among others, can aid clinicians in identifying patients who may need further psychiatric evaluation and support. Although convenient, symptom screening tools are limited by variable sensitivity and specificity and therefore require healthcare professionals to remain vigilant for other mental health "red flags." Ultimately, understanding the connection between allergic disease and mental health empowers clinicians to both anticipate and serve the diverse physical and mental health needs of their patient populations.

The Cost-Effectiveness of Omalizumab for Treatment of Food Allergy

BACKGROUND

Omalizumab is an anti-IgE therapy newly approved by the Food and Drug Administration for allergen agnostic treatment of single or multiple food allergies in patients aged 1 year or older.

OBJECTIVE

Evaluate the cost-effectiveness of omalizumab as a food allergy treatment.

METHODS

We evaluated health and economic outcomes in Markov cohorts of simulated food allergic infants randomized to receive omalizumab using a 15-year horizon. Monte Carlo simulation was used (n = 40,000 subjects) to evaluate cost-effectiveness from a societal perspective, incorporating both a family-level and individual-level analysis. We included family-level analysis to incorporate a broad perspective for health utility change, given treatment effects likely benefit all parties at home (eg, caregivers, siblings), not just the patient, representing the sum of changes in all such persons. Supplemental analyses explored lower omalizumab cost and home initiation. We performed deterministic and probabilistic sensitivity analyses.

RESULTS

In the family-level cohort analysis, omalizumab exceeded cost-effectiveness thresholds ($185,183/quality-adjusted life-years [QALY]). In a comparison of the omalizumab strategy (OMA) with the non-omalizumab strategy, the cost of OMA exceeded the non-omalizumab strategy ($315,020 vs $136,609) with greater incremental effectiveness (12.668 vs 11.699 QALY). In the individual-level analysis, the cost-effectiveness of OMA was $573,698/QALY. In base-case assessments, OMA was cost-effective (willingness to pay, $100,000/QALY) at a health state utility (HSU) improvement of 0.265. The value-based cost of OMA ranged from $14,166 to $23,791 when it was considered at the individual and family-unit levels. Requiring OMA administration in the clinic was not cost-effective (incremental cost-effectiveness ratio, $260,239).

CONCLUSIONS

In the base case and at current pricing, omalizumab is not cost-effective, but it could be at a lower retail price or when use creates large health utility shifts in the family and patient.

Regulation of immune responses to food by commensal microbes

The increasing prevalence of immune-mediated non-communicable chronic diseases, such as food allergies, has prompted a deeper investigation into the role of the gut microbiome in modulating immune responses. Here, we explore the complex interactions between commensal microbes and the host immune system, highlighting the critical role of gut bacteria in maintaining immune homeostasis. We examine how modern lifestyle practices and environmental factors have disrupted co-evolved host-microbe interactions and discuss how changes in microbiome composition impact epithelial barrier function, responses to food allergens, and susceptibility to allergic diseases. Finally, we examine the potential of bioengineered microbiome-based therapies, and live biotherapeutic products, for reestablishing immune homeostasis to prevent or treat food allergies.

Contribution of T cell subsets to different food allergic diseases

Food allergies occur due to a lack of tolerance to the proteins found in foods. While IgE- and non-IgE-mediated food allergies have different clinical manifestations, epidemiology, pathophysiology, and management, they share dysregulated T cell responses. Recent studies have shed light on the contributions of different T cell subsets to the development and persistence of different food allergic diseases. This review discusses the role of T cells in both IgE- and non-IgE-mediated food allergies and considers the potential future investigations in this context.