Oral immunotherapy for food allergy: A Spanish guideline. Egg and milk immunotherapy Spanish guide (ITEMS GUIDE). Part 2: Maintenance phase of cow milk (CM) and egg oral immunotherapy (OIT), special treatment dosing schedules. Models of dosing schedules of OIT with CM and EGG

[Treatment for living with food allergy]

The treatment of food allergy involves completely removing the allergenic food from the diet, careful label reading, and ingredient awareness. Family education is crucial, understanding alternative names for the allergen. An emergency action plan provided by the doctor, with clear instructions for epinephrine application and when to seek medical attention, is essential. For mild to moderate symptoms, oral antihistamines may be prescribed. Psychological support is necessary due to emotional repercussions. Collaboration with an allergy specialist is crucial for personalized treatment. Natural tolerance to the food may be achieved, especially in non-IgE-mediated allergies. However, some allergic manifestations persist, requiring treatment alternatives. Avoidance of the allergen and epinephrine application are key measures. Immunotherapy aims to desensitize immune cells, but its effectiveness varies. Bioterapeutic agents, such as monoclonal antibodies, are under investigation, although their clinical use still requires more studies.

Changes in epidemiology and clinical practice in IgE-mediated Allergy in children

In the last decades, allergic diseases have increased exponentially and although pediatric asthma prevalence is stabilizing, it is estimated around 10% in Spain. Not the same with food allergy and anaphylaxis which are clearly increasing, becoming a significant public health problem. Taking into account epidemiological trends, the European Academy of Allergy and Clinical Immunology (EAACI) estimates that in less than 15 years more than half of the European population will suffer from some type of allergic disorder. The advances in diagnostic methods in food allergy, especially component resolved diagnosis, allow us to know the patient's sensitization profile and explain possible cross reactivity, anticipate potential risk of food trangressions, and prescribe correct avoidance diet in each patient. Thus, the development of molecular biology and nanotechnology have led to the appearance of new technologies (microarrays) which facilitate the study, specially of the polysensitized patients, allowing allergen immunotherapy (AIT) to be more personalized. The latest advances in the use of biologics are having an impact, not only in disease evolution, but also in quality of life.

[Changes in epidemiology and clinical practice in IgE-mediated allergy in children]

In the last decades, allergic diseases have increased exponentially and although pediatric asthma prevalence is stabilizing, in Spain is estimated around 10%. Not the same with food allergy and anaphylaxis which are clearly increasing, becoming a public health problem of the first magnitude. Considering epidemiological trends, the European Academy of Allergy and Clinical Immunology (EAACI) estimates that in less than 15 years more than half of European population will suffer from some type of allergy. The advances in diagnostic methods in food allergy, especially component resolved diagnosis, allow us to know the patient's sensitization profile and explain the possible cross reactivity, anticipate potential risk of food transgressions, and prescribe the correct avoidance diet in each patient. Thus, the development of molecular biology and nanotechnology have led to the appearance of new technologies (microarrays) which facilitate the study, specially of the polysensitized patients, allowing allergen immunotherapy (AIT) to be more personalized. The latest advances in the use of biologics are having an impact, not only in disease evolution, but also in patients quality of life.

Update on food allergy

Food allergy is a major public health issue with growing prevalence in the urbanized world and significant impact on the lives of allergic patients and their families. Research into the risk factors that have contributed to this increase and their underlying immune mechanisms could lead us to definitive ways for treatment and prevention of food allergy. For the time being, introduction of peanut and other allergenic foods in the diet at the time of weaning seems to be an effective way to prevent the development of food allergy. Improved diagnosis and appropriate management and support of food allergic patients are central to patient care with food immunotherapy and biologics making the transition to clinical practice. With the new available treatments, it is becoming increasingly important to include patients' and family preferences to provide a management plan tailored to their needs.

As soon as possible in IgE-cow's milk allergy immunotherapy

Oral immunotherapy is a common treatment in cow's milk protein allergy. The Department of Pediatric Allergology at the Children's Hospital of Zaragoza performed a retrospective analysis of 335 infants under 1 year of age diagnosed with IgE-mediated cow's milk and early treated. Clinical evaluation, skin prick test, and serum-specific IgE level control were performed before starting and after finishing treatment. Upon completion of treatment, more than 98% of patients became tolerant to milk and no one presented serious adverse reactions. Nowadays, the remaining non-tolerant patients (1.8%) can take milk or derivatives daily-as prophylaxis-to a certain maximum dose and still remain asymptomatic. After immunotherapy, both positive skin prick tests and a progressive decrease in specific IgE levels were found, as desensitization to milk increased.Conclusion: Oral immunotherapy is a safe and effective treatment against allergy to cow's milk proteins in infants. Such treatment should be offered to the children's families from the first moment of diagnosis. What is known: • Cow's milk proteins are responsible for the earliest IgE-mediated allergic reactions in children. • Oral immunotherapy (OIT) is commonly used as cow's milk allergy treatment and it is proposed at different ages. What is new: • OIT it is an effective and safe method with no severe reactions at early ages. • The number of reaching successful treatments is awesome so we believe that immunity response can be molded at the first months of life, so the probability of success with infants is greater than in older children.

Oral and sublingual immunotherapy for food allergy

PURPOSE OF REVIEW

To critically appraise the recent most relevant studies in the rapidly advancing field of food oral and sublingual immunotherapy.

RECENT FINDINGS

Food allergen-specific immunotherapy via oral (OIT) and sublingual route (SLIT) increases the threshold of reactivity to peanut, cow's milk, egg, wheat, and many other foods in the majority of the treated individuals. This desensitized state is contingent upon the continued ingestion of the maintenance doses of the food. Permanent oral tolerance is achievable in a smaller subset of the treated individuals. The optimal duration of therapy has not been firmly established but is likely dependent on the phenotype (severity and persistence). Efficacy of food-OIT is superior compared with SLIT, whereas the safety of OIT is less favorable. Standardization of treatment protocols, maintenance dosing, duration of therapy, target populations and harmonization of the outcomes are top priorities at this stage.

SUMMARY

OIT and SLIT represent two different routes of food allergen-specific immunotherapy. Although significant progress has been made in the last decade, both treatment modalities are still in the very early stages of development and further investigations are necessary to optimize the protocols and improve safety while maximizing efficacy.

Successful oral desensitization in children with cow's milk anaphylaxis: Clinical and laboratory evaluation up to nine-years follow-up

INTRODUCTION

Cow's milk protein allergy (CMPA) is the most common food allergy in children worldwide. Some children have severe and persistent CMPA, with near-fatal reactions after exposure to trace amounts of cow's milk-proteins (CMP). Strict avoidance diet is difficult, negatively affects quality of life and represents a conservative approach. Therefore, different therapeutic strategies are necessary.

OBJECTIVE

We aimed to assess long-term efficacy and safety of oral immunotherapy (OIT) in children with severe and long-lasting IgE-mediated CMPA.

MATERIALS AND METHODS

The authors present four case reports of patients with CMPA who underwent CMP-OIT, that have been under long-term follow-up up to nine years. We provide information about the clinical and laboratory evaluation. Skin prick tests (SPT), specific IgE and IgG4 were performed before, during, and after OIT. Immune profile after OIT was assessed by flow cytometry (lymphocyte subsets, regulatory T and B cells).

RESULTS

The success rate was 100%, and all patients currently have a free diet with minimal diary ingestion of 200mL CMP or equivalent. Specific IgE levels and SPT to CMP have progressively decreased, and specific IgG4 levels have increased. CD4⁺CD25⁺CD127^-/dim regulatory T cells were increased after OIT.

CONCLUSIONS

OIT ensured a clinical tolerance state after up to nine years, confirmed by both clinical and immune profile, allowing a diet without restrictions, with high satisfaction from patients and caregivers. We emphasize that OIT should be performed only by allergy experts in the hospital setting, and that only motivated families should be enrolled, since it is essential to ensure CMP daily intake at home.

Cow's milk oral immunotherapy in real life: 8-year long-term follow-up study

Background

Oral immunotherapy (OIT) has been recognized as a promising treatment for severe and long-lasting cow's milk (CM) allergy. Once maintenance has been achieved, patients should maintain daily intake of CM to ensure desensitization. Clinical experience concerning long-term follow-up is scarce.

Objective

The authors aimed to assess long-term efficacy and safety of a maintenance phase of OIT in real life.

Methods

Prospective study of all children and adolescents, who underwent CM-OIT and were subsequently followed at our allergy center on maintenance dose (200 mL daily) for at least 36 months after reaching the maintenance phase (from 2009 to 2016).

Results

Forty-two patients were enrolled: 60% male, 36% with history of anaphylaxis and 57% with asthma. The median time of follow-up was 69 months (range, 39–105 months) and the median age at the last clinical evaluation was 13 years (range, 6–23 years). Regarding adherence to the protocol: 92% are on free diet (at least 200 mL of CM daily; 7-g protein); 14% had transient interruptions and 7% definitely withdrawn with loss of tolerance. During maintenance, 45% developed mild to severe allergic reactions, and 7% had more than 3 episodes. A positive correlation between the occurrence of allergic reactions and history of anaphylaxis (p < 0.001) was found. The coexistence of asthma was risk factor for the occurrence of allergic reactions during maintenance.

Conclusion

This real-life study supports long-term efficacy and safety of CM-OIT. Despite daily intake, 41% had symptoms at some moment during the complete follow-up period; a total of 33 symptomatic days in patients with mean follow-up time of 67.5 months. Clinical tolerance depends on daily intake. The protective effect reached can be lost after CM withdrawal. History of anaphylaxis was a risk factor for the occurrence of allergic reactions during the maintenance phase.