Omalizumab for the Treatment of Multiple Food Allergies

Standardizing outcomes in food allergy research: aligning clinical trials with patient priorities

PURPOSE OF REVIEW

This review explores the clinical outcomes used in immunoglobulin E (IgE)-mediated food allergy (FA) intervention studies, emphasizing unmet need for patient-centred outcomes. Standardizing outcome measurement is critical as research into FA treatments, particularly food immunotherapy, expands. Here we discuss how outcomes should reflect the multidimensional impact of FA on people's lives.

RECENT FINDINGS

Current evidence reveals a discrepancy between clinical trial outcomes and those most valued by patients and carers. While trials often prioritize changes in reactivity thresholds or immunological markers, patients and carers emphasize need in reducing severe reactions, improving quality of life, and enhancing confidence in disease management. This disparity highlights importance of harmonization efforts to guide FA research.The Core Outcome Measures for Food Allergy (COMFA) initiative recently identified two core outcomes - 'allergic symptoms' and 'quality of life' - through an international consensus process involving patients, caregivers, clinicians, and researchers. Outcomes like 'desensitization' and 'remission/sustained unresponsiveness' were considered important but were not seen as the most critical.

SUMMARY

Developing and implementing a COS for FA intervention studies is essential to align research with patient priorities, ensuring meaningful improvements in routine clinical care. Standardized outcome measurement will generate robust evidence, inform clinical practice, and empower patients and caregivers in decision-making about FA management.

Biomarker-driven drug development for allergic diseases and asthma: An FDA public workshop

The US Food and Drug Administration (FDA) hosted a workshop on February 22, 2024, to discuss the status of biomarkers in drug development for allergic asthma and food allergy. The workshop provided a forum for open discussion among regulators, academicians, National Institutes of Health staff and industry to inform stakeholders of the requirements for the FDA to adopt a biomarker as a surrogate end point for a clinical trial, and to inform FDA of the status of various biomarkers in development. The workshop was divided into 3 sessions: (1) FDA and European Union regulators discussing regulatory perspectives on use of biomarkers in drug development programs, (2) investigators discussing biomarkers for pediatric and adult asthma, and (3) investigators discussing biomarkers for food allergy. In this report, we review the information presented at the workshop and summarize the current status of potential biomarkers for these allergic diseases.

Common data elements for food allergy clinical trials: an overview

PURPOSE OF REVIEW

Food allergy represents a major public health issue, affecting about 8% of children and 11% of adults in the United States. Research in the field has rapidly expanded but is limited by a lack of standardized data fields or common data elements (CDEs) to record food allergy data. The present review focuses on the need for developing CDEs for food allergy, and their anticipated impact, as well as describes the central tenets of CDEs.

RECENT FINDINGS

Standardization of data definitions and consistency in data collection within a study and across multiple studies is a fundamental principle of clinical research. Several NIH centers have been collaborating to support the development of CDEs, thereby promoting the FAIR principles for clinical research.

SUMMARY

The population health burden of food allergies continues to rise in the absence of a standardized language for documenting food allergy clinical research data. Development and implementation of food allergy CDEs is needed both nationally and globally, to better understand and reduce the burden of this immune-mediated disease. When adopted, these CDEs will not only improve data consistency and interoperability but also speed up and improve the quality of future food allergy clinical trials.

Brain Delivery Strategies for Biomacromolecular Drugs: Intranasal Administration

Macromolecular Drugs (including monoclonal antibodies, recombinant proteins, and nucleic acid therapies) have become a cornerstone strategy for intervening in complex pathological mechanisms such as cancer, autoimmune diseases, and genetic disorders due to their high specificity for disease targets and low off-target toxicity. However, compared to traditional small-molecule drugs, the high molecular weight (>10 kDa) and structural complexity of macromolecular drugs result in extremely low transmembrane permeability. This is particularly challenging in the treatment of central nervous system (CNS) diseases, where the blood-brain barrier (BBB) imposes stringent selectivity, further limiting drug delivery efficiency. This review focuses on the breakthrough strategy of nose-to-brain (NtB) drug delivery. On one hand, the NtB pathway bypasses the BBB, enabling direct CNS drug delivery. On the other hand, nanocarrier technology can synergistically achieve systemic delivery and brain-targeted transport. Based on the latest research advances, this article systematically examines the feasibility of delivering macromolecular drugs via NtB administration. We comprehensively summarize relevant delivery carriers and discuss the potential advantages of intranasal-brain delivery for CNS disease treatment. Notably, while significant progress has been made in this field, further exploration is still needed regarding the mechanisms of NtB delivery and challenges in clinical translation.

Biologic Therapies for Severe Asthma: Current Insights and Future Directions

Severe asthma is a subset of difficult-to-treat asthma that requires the verification of inhaler technique, the correction of modifiable risk factors, as well as diagnosis and comorbidity review. When severe asthma is suspected, patients should undergo proper phenotyping (T2-high or T2-low) and be referred to a specialized severe asthma clinic. The current biologics for severe asthma treatment include omalizumab (anti-IgE), mepolizumab and reslizumab (anti-IL-5), benralizumab (anti-IL-5 receptor), dupilumab (anti-IL-4/IL-13), and tezepelumab (anti-TSLP). The outcomes to evaluate are the reduction in systemic corticosteroid use, the reduction in exacerbations and healthcare use, and improvement in symptoms and lung function. Comorbidities should be carefully considered, and if possible, addressed with the same biologic. Dupilumab, mepolizumab, and omalizumab are also approved for chronic rhinosinusitis with nasal polyps (CRSwNP), the most common asthma comorbidity. There are currently several clinical trials on biologics for severe asthma. Depemokimab is an ultra-long-acting anti-IL-5 antibody with promising results in phase III trials as a twice-yearly biologic for T2-high asthma. Verekitug follows a similar dosing concept, targeting TSLP, but is still undergoing phase II trials. Itepekimab and astegolimab are two anti-IL-33 antibodies that could have a role in the future treatment of severe asthma. Tezepelumab is in a phase III clinical trial for CRSwNP. Besides new drugs, there is still a need for major research into biologics in severe asthma cases, namely with comparative studies, better biomarkers for predicting response, and the determination of optimal treatment duration.

Want to help your patients with food allergy anxiety? Do proximity challenges!

Excessive anxiety regarding the potential for accidental and fatal cross-contamination is very common among patients and families with food allergy and contributes significantly to burden, reduced quality of life, and poorer management. In their landmark paper published nearly a decade ago, Dr Chitra Dinakar and colleagues recommended that food allergists incorporate proximity food challenges such as smelling or touching an allergen into regular clinical practice to improve patient knowledge regarding safety and relative risk and reduce anxiety. Such proximity challenges are akin to the exposure tasks routinely used to treat anxiety in cognitive-behavioral therapy, the first-line psychosocial intervention for anxiety disorders. Exposure is a highly evidence-based therapy technique in which patients-guided and encouraged by their providers-directly and strategically confront a feared object, situation, or activity. Anxiety eventually diminishes and erroneous beliefs are corrected when exposures happen repeatedly in the absence of the feared negative outcome. Following a summary of the history and evidence base for exposure in both the psychiatric and food allergy literature, we review several considerations related to conducting in-office proximity challenges. Topics include in-office assessment of food allergy anxiety and medically unnecessary avoidance; choosing appropriate, individualized proximity challenges based on patient presentation; and practical considerations in carrying out in-office proximity challenges to maximize benefits to anxious patients.

Insulin Allergy: The Allergist's Updated Approach to Evaluation and Management

The transformative discovery of insulin in the early 20th century followed by its rapid clinical implementation was initially complicated by high rates of hypersensitivity reactions. Improvements in purification methods and the transition from animal-derived sources to human insulin products has significantly lowered, although not eliminated, hypersensitivity reactions to insulin. Although considered rare adverse reactions to insulin, hypersensitivity reactions and immune-mediated manifestations continue to occur in patients requiring insulin treatment. This has broad implications given that approximately 11.6% of the US population has a diagnosis of diabetes and 8.4 million Americans rely on insulin for survival. Because of the scope and impact of insulin as a life-saving treatment for patients with diabetes, it is important for allergists to evaluate, provide a diagnose for, and manage patients with hypersensitivity reactions to insulin appropriately. Recognizing early manifestations of insulin hypersensitivity is the first step in providing prompt and targeted management in these complex cases. The following article aims to summarize the allergist's recommended approach to insulin hypersensitivity reactions, including type I IgE-mediated and type III immune-complex mediated reactions, type IV T-cell mediated hypersensitivity reactions, as well as additional immune-mediated manifestations of insulin therapy such as lipoatrophy and insulin autoantibodies. Furthermore, the authors emphasize approaching insulin hypersensitivity cases with a broad differential diagnosis, which includes hypoglycemia, anaphylaxis mimics, hypersensitivity to excipients and medical devices, and cutaneous manifestations of diabetes.

Efficacy and Safety of Epicutaneous Immunotherapy in Peanut-Allergic Toddlers: Open-Label Extension to EPITOPE

BACKGROUND

The pivotal phase 3 EPITOPE trial, a 12-month, double-blind, placebo-controlled study of epicutaneous immunotherapy with the VIASKIN patch containing 250 μg of peanut protein (VP250), previously reported significant treatment response versus placebo in peanut-allergic toddlers aged 1 through 3 years.

OBJECTIVE

To assess the interim efficacy and safety of VP250 from the first year of the EPITOPE open-label extension (OLE) study.

METHODS

Eligible participants enrolled in the OLE study for up to 3 years of total treatment with annual double-blind, placebo-controlled food challenges (DBPCFCs) and safety assessments; here we report the first-year OLE (year 2) results.

RESULTS

A total of 266 EPITOPE participants enrolled in the OLE study; 244 underwent month 24 DBPCFC (n = 166 VP250; n = 78 placebo). After 24 months of VP250, 81.3% reached an eliciting dose (ED) ≥1000 mg, 63.8% reached an ED ≥2000 mg, and 55.9% completed the DBPCFC (cumulative dose: 3444 mg) without meeting stopping criteria. No treatment-related anaphylaxis or serious treatment-related adverse events occurred during year 2 in this treatment arm. Local application-site reactions occurred less frequently in year 2 versus year 1. In placebo-treated EPITOPE participants, outcomes after 1 year of open-label VP250 were consistent with EPITOPE treatment results: 62.7% reached an ED ≥1000 mg, 36.5% reached an ED ≥2000 mg, and 28.4% completed the DBPCFC without meeting stopping criteria; and there was 1 treatment-related anaphylaxis event.

CONCLUSIONS

Two years of VP250 in young peanut-allergic children demonstrated continued increases in treatment effect without new safety signals. This supports the potential of VP250 as a safe and effective treatment for peanut allergy in young children.

CLINICALTRIALS

GOV: NCT03859700.

Antigenic determinants underlying IgE-mediated anaphylaxis to peanut

BACKGROUND

Studies of human IgE and its targeted epitopes on allergens have been very limited. We established a method to immortalize IgE-encoding B cells from patients with allergy.

OBJECTIVE

We sought to develop an unbiased and comprehensive panel of peanut-specific human IgE mAbs to characterize key immunodominant antigenic regions and epitopes on peanut allergens to map molecular interactions responsible for inducing anaphylaxis.

METHODS

Using human hybridoma technology to immortalize IgE-encoding B cells from peripheral blood of subjects with severe peanut allergy, we generated a panel of naturally occurring human IgE mAbs in an unbiased manner. Isolated IgE mAbs were characterized extensively in allergen binding assays, peptide array analysis, antigenic mapping, binding kinetic analysis, serum blocking, skin testing inhibition, and functional assessment using human FCεRI transgenic mice.

RESULTS

We created a large panel of 54 peanut-specific IgE mAbs, of which 63% were specific for Ara h 2 and/or Ara h 6. Pairs of IgE mAbs with the same antigen specificity but different binding sites were able to mediate passive systemic anaphylaxis in FCεRI transgenic mice. A single mAb targeting the repetitive motif on Ara h 2 was able to induce degranulation and anaphylaxis on its own. IgG1 switch variant immunoglobulins of the IgE mAb inhibited binding of 30% to 60% of patients' IgE to peanut extract (ImmunoCAP) and reduced peanut extract-induced skin wheal sizes by 1.6 to 7.4 mm in patients with peanut allergy.

CONCLUSION

We created a molecular map of the IgE antibody response to the most important peanut allergen proteins to enable the design of new allergy immunotherapies and vaccines.

Anaphylaxis in children: Latest insights

Background: The diagnosis and management of anaphylaxis in pediatric populations can be a particularly formidable challenge due to its variable definitions and atypical symptom presentation, which can often masquerade as other conditions. This complexity often leads to delays in early recognition and timely intervention. Most pediatric anaphylaxis guidelines emphasize the importance of identifying and avoiding triggers, ensuring accurate dosing and prompt administration of epinephrine to prevent severe complications. There is also growing scientific interest in strategies to intervene early in food allergy development to prevent allergies and protect infants and children from severe allergic reactions. Objective: This report aimed to review key aspects of the pathophysiology, epidemiology, management, and prevention of anaphylaxis in the pediatric population. Also, approved treatment modalities and future research to treat and prevent anaphylactic reactions are discussed. Methods: A review of the medical literature was conducted by using terms that included anaphylaxis, severe allergic reaction, pediatric, prevalence, desensitization, and immunotherapy. Results: Food allergies remain the leading trigger of pediatric anaphylaxis, followed by Hymenoptera venom, whereas drug allergies are less common in children compared with adults. A review of the literature underscores the importance of recognizing early signs and symptoms of anaphylaxis, particularly in preverbal infants, of identifying and eliminating key triggers and of prompt epinephrine administration in the immediate management of pediatric anaphylaxis. Advances in oral immunotherapy and other treatments (e.g., biologics) provide new management options. Notably, anti-immunoglobulin E therapy with omalizumab has shown substantial protection against reactions to accidental food exposure in children as young as 1 year old and with food allergy. Conclusion: This report explores critical aspects of anaphylaxis that affect allergic diseases in infants and children. Gaining a deeper understanding of age-specific triggers and the diverse symptoms of anaphylaxis will significantly enhance diagnosis, treatment, and prevention strategies, ultimately improving the timeliness of interventions. Recent approvals of novel therapies for food allergies, along with promising developments for future treatment and prevention of anaphylaxis in pediatric populations, hold exciting potential for better management of these conditions.

Long-Term Safety of Epicutaneous Immunotherapy in Peanut-Allergic Children: An Open-Label Active Treatment (REALISE Study)

BACKGROUND

Owing to limited treatment options for peanut allergy, patients remain at risk for allergic reactions due to accidental exposure. Epicutaneous immunotherapy (EPIT) is a novel treatment being investigated for peanut allergy.

OBJECTIVE

This study assessed long-term safety of EPIT with VIASKIN peanut patch 250 μg (VP250) via an open-label extension of the REAL Life Use and Safety of EPIT (REALISE) trial.

METHODS

REALISE was a phase 3 trial in peanut-allergic children aged 4 through 11 years that included a 6-month, randomized, double-blind, placebo-controlled treatment phase, followed by an open-label, single-arm, active treatment period for up to 36 months.

RESULTS

Of the 392 participants (male 54.8%; median age 7.2 y) who received at least 1 dose of treatment, 77.8% completed the 36-month active treatment. Mean adherence to treatment was high at 96.4%. Most participants (98.7%) experienced at least 1 treatment-emergent adverse event (TEAE); the majority were mild or moderate and decreased in frequency and severity over time. Most participants (94.6%) experienced at least 1 treatment-related TEAE. Local skin reactions were the most common treatment-related TEAE with the incidence decreasing from year 1 (87.8%) to year 3 (19.2%). Serious treatment-related TEAEs were reported in 2 participants. No specific safety signals were identified in the 14 participants enrolled with a history of severe anaphylaxis (Anaphylaxis Staging System grade 3).

CONCLUSION

Consistent with previous phase 3 studies, long-term EPIT with VIASKIN peanut patch 250 μg was well tolerated with high adherence in peanut-allergic children aged 4 through 11 years (clinicaltrials.gov; NCT: NCT02916446).

Scientific developments in understanding food allergy prevention, diagnosis, and treatment

Food allergies (FAs) are adverse immune reactions to normally innocuous foods. Their prevalence has been increasing in recent decades. They can be IgE-mediated, non-IgE mediated, or mixed. Of these, the mechanisms underlying IgE-mediated FA are the best understood and this has assisted in the development of therapeutics. Currently there are two approved drugs for the treatment of FA, Palforzia and Omalizumab. Palfornia is a characterized peanut product used as immunotherapy for peanut allergy. Immunotherapy, involves exposure of the patient to small but increasing doses of the allergen and slowly builds immune tolerance to the allergen and increases a patient's allergic threshold. Omalizumab, a biologic, is an anti-IgE antibody which binds to IgE and prevents release of proinflammatory allergenic mediators on exposure to allergen. Other biologics, investigational vaccines, nanoparticles, Janus Kinase and Bruton's tyrosine kinase inhibitors, or DARPins are also being evaluated as potential therapeutics. Oral food challenges (OFC) are the gold standard for the diagnosis for FA. However, they are time-consuming and involve risk of anaphylaxis; therefore, alternative diagnostic methods are being evaluated. This review will discuss how the immune system mediates an allergic response to specific foods, as well as FA risk factors, diagnosis, prevention, and treatments for FA.

Omalizumab in Food Allergy in Children: Current Evidence and Future Perspectives

Omalizumab (OMA) is gaining recognition as a promising therapeutic approach for IgE-mediated food allergies in pediatric patients. We conducted a review analyzing 22 studies, including randomized controlled trials, observational studies, and case reports, to evaluate the efficacy and safety of OMA in food allergy management in children and adolescents. The results indicate that OMA, whether used as monotherapy or in combination with oral immunotherapy (OIT), significantly increases allergen tolerance, reduces the severity of allergic reactions, and improves patients' quality of life. When used alongside OIT, OMA reduced adverse reactions during dose escalation and maintenance phases, facilitating safer and more effective desensitization. Additionally, OMA demonstrated benefits beyond food allergy management, including improved asthma control and a reduction in food allergy-related anxiety. However, challenges remain, including high costs, the need for standardized treatment protocols, and limitations related to total IgE thresholds for eligibility. While OMA has been FDA-approved for food allergy treatment in the United States, further research is needed to establish long-term efficacy, optimal dosing strategies, and its role in sustained tolerance development. Future research should focus on optimizing treatment protocols and identifying which patients will benefit the most. Integrating omalizumab into food allergy management could revolutionize pediatric care, offering hope for a safer, more effective approach to desensitization.

Baseline basophil activation and early suppression is associated with clinical outcome after peanut sublingual immunotherapy

BACKGROUND

Sublingual immunotherapy (SLIT) was recently shown to safely induce desensitization and remission of peanut allergy in 1- to 4-year-old children.

OBJECTIVE

Basophil activation has been shown to be suppressed in allergen-specific immunotherapy. We aimed to evaluate the timing of basophil suppression during peanut SLIT and its impact on clinical outcomes.

METHODS

A total of 50 children with peanut allergy were enrolled in a peanut SLIT trial and randomized to active peanut or placebo SLIT for 36 months followed by a 3-month avoidance period to evaluate remission. To measure basophil activation by CD63 and CD203c, blood was collected at baseline and again at 12, 24, 36, and 39 months.

RESULTS

For participants receiving peanut SLIT, basophil activation based on CD63 expression was significantly reduced by 12 months and continued to decrease throughout peanut SLIT, whereas CD63 activation in participants receiving placebo remained unchanged from 0 to 36 months. CD203c expression remained unchanged for both peanut SLIT and placebo participants throughout the trial. Actively treated participants who achieved remission had lower CD63 expression at baseline and significant suppression of CD63 expression by 12 months, whereas participants who failed treatment had higher CD63 expression at baseline and lack of suppression by 12 months. Lower basophil activation in those achieving remission, compared to those who failed treatment, remained present for up to 3 years.

CONCLUSIONS

Following peanut SLIT, participants who achieved remission had significantly suppressed basophil activation by 12 months compared to unsuccessful participants who were not desensitized, suggesting that early suppression of basophils may be indicative of peanut SLIT efficacy.

The clinical and pathological histology efficacy of biological therapy for severe asthma with a phenotype of type 2 inflammation - systematic review

Asthma is a complex, chronic inflammatory condition of the airways that comes in many forms. Because different inflammatory processes drive it, we can generally categorize asthma into two main types: type 2 inflammatory asthma and non-type 2 inflammatory asthma. Type 2 inflammation is usually the culprit in most folks grappling with severe asthma. There is a noticeable difference in the treatment approaches for different phenotypes of severe asthma. The main reason is that patients suffering from type 2 inflammatory asthma can respond well to treatment with biological agents. Several well-verified biological agents, such as anti-immunoglobulin E (IgE) monoclonal antibodies, anti-interleukin (IL)-4 monoclonal antibodies, anti-IL-5 monoclonal antibodies, and anti-thymic stromal lymphopoietin (TSLP) monoclonal antibodies, have shown outstanding effectiveness. They can significantly alleviate asthma exacerbations, lower the number of eosinophils, improve pulmonary function, decrease the dependence on oral corticosteroids, and elevate the quality of life for patients with asthma. This discourse meticulously evaluates the therapeutic prowess of biological agents in the treatment and control of severe asthma, concurrently investigating their impact on histological indices, to highlight the crucial role of precision medicine in the strategic concatenation of therapy for this refractory malady.

A comprehensive guide to food allergy management for the general pediatrician

There has been an increase in the prevalence of food allergy among children in the United States. Pediatricians play a pivotal role in caring for children with food allergy, as they are often the first point of contact and enjoy longitudinal relationships with families. In this review, we discuss the epidemiology, risk factors, presentation, diagnosis, and management of food allergy. We also discuss special considerations for patients with food allergy, including nutritional risks and psychosocial stressors that may negatively influence children's wellbeing. Our goal is to provide a concise yet comprehensive guide for general pediatricians so they may feel confident providing high-quality care for patients with food allergy.

Omalizumab reduces anaphylactic reactions and allows food introduction in food-allergic in children with severe asthma: An observational study

BACKGROUND

In Europe, Omalizumab (anti-IgE) is indicated for the treatment of moderate to severe asthma, but not for IgE-mediated food allergy (FA).

OBJECTIVE

We assessed the impact of Omalizumab on efficacy, safety, and quality of life (FA-QoL) in patients with moderate to severe asthma and who have a history of anaphylaxis to peanut, tree nuts, fish, egg, milk, and/or wheat.

METHODS

Food-allergic children (6-18 years) with moderate to severe asthma underwent oral food challenges (OFCs) to establish the threshold of reaction to the culprit food(s) at baseline (T0) and at 4-month intervals (T1, T2, and T3) during their first year of treatment with Omalizumab. We recorded the number and severity of food-allergic reactions, Asthma Control Test (ACT) scores, FA-QoL, and total IgE levels.

RESULTS

In 65 patients allergic to 107 foods, the No Observed Adverse Events Level (NOAEL) at T1 increased: 243- and 488-fold for fresh and baked milk, respectively; 172- and 134-fold for raw and baked egg; 245-fold for hazelnut; 55-fold for peanut; 31-fold for wheat; and 10-fold for fish. Full tolerance was achieved in 66.4% of OFCs at T1, 58.3% at T2, and 75% at T3. Ninety-five foods were liberalized in the diet of 55 patients; the remaining 12 were introduced by 10 patients at least in traces. Throughout the study, 40 out of 65 were able to get a free diet. ACT increased from 17 (Q1-Q3: 15-17) to 23.6 (Q1-Q3: 23-25). The FA-QoL score in children ≤12 years decreased from 4.63 ± 0.74 to 2.02 ± 1.13, and in adolescents from 4.68 ± 0.92 to 1.90 ± 1.50.

CONCLUSIONS

During Omalizumab therapy, a safe reintroduction of allergenic foods is feasible.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov, NCT06316414.

The ethics of food allergy

PURPOSE OF REVIEW

Ethical dilemmas are a common occurrence in the provision of care to individuals with food allergies. Thus, an understanding of medical ethics is essential for allergists/immunologists.

RECENT FINDINGS

Despite the importance of medical ethics in the clinical practice of food allergy, there has been little published on this topic. Some international allergy societies have published ethical guidelines. Further investigation on medical ethics in food allergy is required.

SUMMARY

This review describes key ethical principles in relation to food allergy testing, oral food challenges, and various management strategies, including avoidance, omalizumab and oral immunotherapy. This review demonstrates the necessity for education and research on medical ethics in food allergy.

Food Allergy, Nutrition, Psychology, and Health

This article explores food allergy and the nascent field of nutritional psychiatry. Individuals with food allergy experience lower levels of "food freedom" than their nonallergic counterparts, which can create cognitive, emotional, social, nutritional, and financial burdens. Patterns of food avoidance may influence neuroinflammatory states and the gut microbiome; these changes may be associated with neuropsychiatric symptoms. Food restriction may promote disruption of the microbiome neuroimmune axis, which has been linked to various allergic diseases. Targeted psychological counseling strategies can provide benefit. Food allergy and restricted diets may impact dietary health benefits.

The Multiple Facets of Cow's Milk Allergy

Cow's milk allergy (CMA) is one of the most common food allergies in early childhood. CMA has varied presentations and multiple facets. A detailed clinical history is key for classification. In IgE-mediated CMA, skin prick testing and serum specific IgE testing are useful in the diagnosis, but an oral food challenge may still be necessary if there is doubt or to assess tolerance. Non-IgE-mediated CMA presentations include food protein-induced allergic proctocolitis, food protein-induced enterocolitis syndrome, and eosinophilic esophagitis. The diagnosis of food protein-induced allergic proctocolitis and food protein-induced enterocolitis syndrome is based on the clinical history. An esophageal biopsy is required for the diagnosis of eosinophilic esophagitis. Atopy patch testing, IgG testing, or IgG4 testing is not helpful in any CMA evaluation. Children with CMA (except those with food protein-induced allergic proctocolitis) are at risk for poor growth, and a nutritional evaluation should be part of routine care. Extensively hydrolyzed formulas are the recommended first-choice alternative formula for CMA. For IgE-mediated CMA, alternative approaches to traditional strict avoidance include oral immunotherapy and omalizumab (both as monotherapy and as an adjunct to oral immunotherapy). Multiple international guidelines have addressed evaluation and management of CMA, providing key information, support, and guidance for clinicians in daily practice.

The combination of allergen immunotherapy and biologics for inhalant allergies: Exploring the synergy

The development of monoclonal antibodies that selectively target IgE and type 2 immunity has opened new possibilities in the treatment of allergies. Although they have been used mainly as single therapies found to have efficacy in the management of asthma and other T2-mediated diseases, there is a growing interest in using these monoclonal antibodies in combination with allergen immunotherapy (AIT). AIT has transformed the treatment of allergic diseases by aiming to modify the underlying immune response to allergens rather than just providing temporary symptom relief. Despite the proven efficacy and safety of AIT, unmet needs call for further research and innovation. Combination strategies involving biologics and AIT exhibit potential in improving short-term efficacy, reducing adverse events, and increasing immunologic tolerance. Anti-IgE emerges as the most promising therapeutic strategy, not only enhancing AIT's safety and tolerability but also providing additional evidence of efficacy compared with AIT alone. Anti-interleukin-4 receptor offers a reduction in adverse effects and an improved immunologic profile when combined with AIT; however, its impact on short-term efficacy seems limited. The combination of cat dander subcutaneous immunotherapy with anti-thymic stromal lymphopoietin was synergistic with enhanced efficacy and altered immune responses that persisted for 1 year after discontinuation compared with AIT alone. Long-term studies are needed to evaluate the sustained benefits and safety profiles of combination strategies.

Evolving Food Allergy Clinical Trials to Become More Patient-Centered

The current US Food and Drug Administration (FDA) paradigm may not fully capture important patient-centered outcomes or measure a primary outcome that is truly meaningful to patients. Patient-reported outcome measures (PROMs) are standardized tools measuring the patient's experience in food allergy clinical trials, which can help support shared decision-making (SDM) and further our understanding of treatment impact. Food allergy PROMs include quality of life (QoL), health state utility (HSU), severity, and self-efficacy measures. Currently, FDA registration trials for product approval only consider a fixed increase in allergen threshold from pre-to-post intervention as a primary outcome (vs a more flexible "X-fold" increase not accounting for an upper and lower specific threshold), though many use QoL as a secondary outcome for patient-centered assessment of treatment impact. Currently used QoL PROMs were not designed to measure change on therapy nor measure HSU (eg, quantitative risk a patient may be willing to take to improve their current health), which can be used to determine therapy value. Although the current paradigm for primary and secondary outcomes in food allergy clinical trials was appropriate at the early stages of food allergy therapy development when conceived in the late 2000s and early 2010s, in the 2020s, these outcome choices risk being stagnant and outdated. As such, the current paradigm for food allergy outcomes should evolve to incorporate more patient-centered primary outcome measures that patient data indicate are meaningful, so outcomes more realistically reflect a therapy's impact. This evolution will better support SDM discussions as patients consider their therapy options and can inform new product development.

Efficacy of omalizumab in food allergic adults - A retrospective analysis

Background

IgE-mediated food allergy poses a significant public health concern, currently with no approved therapies for adults in Europe. Omalizumab (OMA) used as monotherapy or in conjunction with oral immunotherapy (OIT) has been suggested as an efficacious treatment for severe food allergy. The aim of this study was to analyze real-world data from food-allergic patients treated with OMA.

Methods

We included food-allergic patients treated with OMA between 2002 and 2022 throughout Europe. Treatment responders (TR) were identified based on the unresponsiveness to related food allergens (determined by food challenge), reduction in the severity of food allergy and absence of anaphylactic reactions.

Results

Sixty-two patients (female n = 39/62, 62.9%; mean age 30.6 years) were included into this analysis, most of whom were polysensitized to more than 2 food allergens (n = 40/62, 64.5%); 45/62 patients (72.6%) received OMA in conjunction with OIT, while the remaining patients underwent OMA monotherapy. The eliciting food allergens were tree nuts (n = 27/62, 43.5%), cow's milk (n = 26/62, 41.9%), and vegetables (n = 25/62, 40.3%). In most cases, OMA was initiated with 300 mg q4w (n = 51/62, 82.3%) dosing. Treatment was tolerated exceptionally well.Fifty-two (52/62) patients (83.9%) were classified as treatment responders. Six (6/62) patients (9.7%) developed unresponsiveness, 6/62 (9.7%) had a reduction of the severity of food allergy, and 40/62 (64.5%) had no further anaphylactic reactions during treatment. One (1/62) patient (1.6%) undergoing monotherapy was a non-responder, exhibiting repeated anaphylactic reactions to accidental exposures, and 10/62 patients (16.1%) reported anaphylactic reactions during treatment. In most of these cases, cofactors (n = 5/10, 50%) were present.

Conclusion

Our real-world evidence data indicate efficacy and tolerability of OMA for the treatment of IgE-mediated food allergy with and without OIT. As the onset of food related reactions upon treatment was frequently linked to the presence of cofactors, these should be identified and considered in patients with food allergy-not only for diagnosis, but also in treatment settings.

Updates in Food Anaphylaxis Management

The management of food allergy has evolved over the past several years with regulatory approval of food allergy therapeutics as well as the common practice of oral immunotherapy. Whether a patient or family chooses one of these therapies or avoidance, they are still considered at risk of reaction, and thus clinicians still need to stay up to date with the latest advancements in the management of anaphylaxis in patients with food allergy. This review will highlight some of these updates, starting with the definition, diagnosis, and classifications of anaphylaxis. It will then review the latest updates in the management of food anaphylaxis in the community. Finally, the review will discuss the latest in epinephrine including recommendations on epinephrine dosing and novel routes of epinephrine administration.

Treatment of Food Allergy: Immunotherapy, Omalizumab, or Both

Food allergy is a common disease that has substantial impacts on the quality of life of patients and their families, and all reactions have the potential for causing life-threatening anaphylaxis. Food-allergic individuals currently have 2 Food and Drug Administration- approved therapeutic options available to them aside from life-long allergen avoidance: oral immunotherapy (OIT) and omalizumab. OIT for food allergy has been extensively studied in clinical trials and currently provides the greatest level of protection; however, it also has a high burden of treatment. Studies suggest that more successful OIT outcomes may be attained with earlier intervention; however, early OIT presents its own challenges. Omalizumab, recently Food and Drug Administration-approved, is a biologic targeting IgE, a major driver of allergic reactions. In contrast to OIT, omalizumab monotherapy offers a low treatment burden therapeutic option that provides a safety net against reactions to accidental ingestion of multiple allergens. In addition, omalizumab has been investigated as an adjunct to OIT, improving the speed and safety of single-allergen or multiallergen OIT. Here, we discuss the clinical use of these therapeutic options and provide a guide for shared decision making between patients and physicians about what therapeutic option might be more appropriate.

Total Serum IgE in a Cohort of Children With Food Allergy

BACKGROUND

Total serum IgE (TsIgE) has not been examined in children with food allergy.

OBJECTIVE

To evaluate associations of TsIgE with patient, household, environmental, and community-level characteristics among children with food allergy.

METHOD

We used linear mixed-effects models of data from 398 Black and/or African American (B/AA) and White and/or European American (W/EA) children with allergist-diagnosed food allergy from the multicenter, observational cohort FORWARD (Food Allergy Outcomes Related to White and African American Racial Differences); TsIgE (kU/L) was the primary outcome measure.

RESULTS

In univariable analyses of data from all study sites, children's TsIgE was positively associated with older age (P < .001); B/AA race (P < .001); male sex (P = .014); lower household income (P = .005); lower caregiver education (P = .005); higher Area Deprivation Index (P < .001); presence of allergic rhinitis (P < .001), asthma (P < .001), and eczema (P = .024); and a higher number of food allergies (P < .001), but not with tobacco smoke exposure. With covariable adjustment in multivariable analysis, total serum IgE was higher in older versus younger children (P < .001), male versus female children, B/AA versus W/EA children (P < .001), and in children with allergic rhinitis (P = .010), asthma (P < .001), eczema (P = .007), or a higher number of food allergies (P < .001), but not with tobacco smoke exposure or Area Deprivation Index.

CONCLUSIONS

In children with food allergy, age, sex, race, atopic diagnosis, allergic rhinitis, asthma, and eczema are associated with TsIgE. These findings are important when TsIgE values are used in diagnosis and therapies.

Vascular Pathogenesis in Acute and Long COVID: Current Insights and Therapeutic Outlook

Long coronavirus disease 2019 (COVID-19)-a postacute consequence of severe acute respiratory syndrome coronavirus 2 infection-manifests with a broad spectrum of relapsing and remitting or persistent symptoms as well as varied levels of organ damage, which may be asymptomatic or present as acute events such as heart attacks or strokes and recurrent infections, hinting at complex underlying pathogenic mechanisms. Central to these symptoms is vascular dysfunction rooted in thrombotic endothelialitis. We review the scientific evidence that widespread endothelial dysfunction (ED) leads to chronic symptomatology. We briefly examine the molecular pathways contributing to endothelial pathology and provide a detailed analysis of how these cellular processes underpin the clinical picture. Noninvasive diagnostic techniques, such as flow-mediated dilation and peripheral arterial tonometry, are evaluated for their utility in identifying ED. We then explore mechanistic, cellular-targeted therapeutic interventions for their potential in treating ED. Overall, we emphasize the critical role of cellular health in managing Long COVID and highlight the need for early intervention to prevent long-term vascular and cellular dysfunction.

Infant and Toddler Peanut Oral Immunotherapy: Initiation Before Age 2 Increases Ad Libitum Peanut Consumption

BACKGROUND

Peanut oral immunotherapy (POIT) has promising potential of disease modification, but there are no studies to date evaluating high-dose POIT, leading to ad libitum (ad lib) consumption of peanut products, especially in children 6 months to 4 years of age.

OBJECTIVE

To report real-world outcomes of high-dose POIT in children 6 months to 4 years of age, including adverse events, achievement of ad lib consumption, and the impact of age on these outcome measures.

METHODS

Patients 6 months to 4 years of age with a diagnosis of peanut allergy were enrolled in a POIT protocol with a goal dose of 3000 mg. Demographics along with POIT and clinical outcomes 6 months after POIT are reported.

RESULTS

Sixty children, with a median age of 16 months, started POIT. Three (5%) were lost to follow-up, and 6 (10%) discontinued POIT because of recurrent adverse events or the inability to consume daily peanut protein. Fifty-one (85%) children completed POIT in a median of 7 months and were consuming ad lib peanut products for a duration of 6 months after completion of the POIT protocol. Sixteen (26.7%) children experienced a total of 22 adverse reactions during POIT. Initiating POIT before 24 months of age increased the likelihood of ad lib peanut consumption by an odds ratio of 11.69 (1.19-114.31, P = .035).

CONCLUSIONS

Our study demonstrates that high-dose POIT in infants and toddlers is well tolerated and can lead to ad lib introduction of dietary peanut products into the diet, especially if initiated before 2 years of age.

Moving Beyond Desensitization to Tolerance in Food Allergy

Management of IgE-mediated food allergy is shifting from reactive management strategies (allergen avoidance and ready access to autoinjectable epinephrine in case of exposure) to proactive therapies. These therapies are in various stages of clinical development and implementation; the two main approaches include allergen-specific or active therapies (induce the immune system to produce a protective response to the allergen; eg, Food and Drug Administration-approved AR101/Palforzia (peanut [Arachis hypogaea] Allergen Powder-dnfp; PTAH, also known as AR101) (Aimmune Therapeutics, Inc., Brisbane, CA) for peanut allergy), and allergen-agnostic, passive therapies (provide the body with the tools needed to suppress immediate hypersensitivity reactions in a nonspecific manner; eg, Food and Drug Administration-approved omalizumab). These therapies provide a similar degree of protection, specifically desensitization (increased reaction threshold while receiving food allergy therapy, bite safety), but differ in mechanisms, dosing protocols, and side effects. The goals of therapeutics in development are shifting to sustained unresponsiveness or remission (absence of clinical reactivity after allergen and food allergy therapy avoidance, typically for weeks to months) and tolerance (no clinical reaction or free ingestion of the allergen). As the food allergy management repertoire expands, important considerations in selecting a therapy will be patient-specific and include mode of delivery, dosing regimens, side-effect profiles, and goals or outcomes. The role of shared decision making and implementation strategies to support equitable access across patient populations and clinical contexts will be critical to move an increasing number of patients beyond desensitization to tolerance, if they wish.

The Art of Clinical Negotiation

The art of clinical negotiation is an important, yet underappreciated aspect of medicine. Key components of negotiation include the need to consider principles over personalities; to explore all options before deciding on the best course; to realize that, if consensus cannot be achieved, then compromise may still be possible; to work from evidence to incorporate contextual factors; and to stay evidence based. These principles can be helpful in many settings, including contract negotiation, drug pricing, and research. Negotiating the balance between patient safety and efficient research methodology is central to discussions with institutional review boards and public and private researchers. When guidelines are developed using the Grading of Recommendations Assessment, Development and Evaluation approach, shared decision making and negotiation of treatment plans can be seamlessly incorporated into patient conversations for conditional recommendations, and negotiation skills may facilitate clinical adoption of strong recommendation as well.

New approaches in childhood IgE-mediated food allergy treatment

PURPOSE OF REVIEW

This review aims to provide an overview of the current and future treatment options for children with food allergies (FAs), highlighting the latest research findings and the potential impact of these new approaches on improving patients' and caregivers' quality of life.

RECENT FINDINGS

In the last decade, many promising approaches have emerged as an alternative to the standard avoidance of the culprit food with the risk of severe accidental reactions. Desensitization through oral immunotherapy has been introduced in clinical settings as a therapeutic approach, and more recently also omalizumab. In addition, alternative routes of administration for immunotherapy, other biologics, small molecules, probiotics or prebiotics, microbiota transplantation therapy, IGNX001, and PVX108 are being investigated.

SUMMARY

The portfolio of available treatment options for food allergies is increasing but several relevant unmet needs remain. This review aims to provide a brief overview of the existing and future treatment options for IgE-mediated food allergies.

Epicutaneous immunotherapy: A review of safety and efficacy

Epcutaneous immunotherapy (EPIT) is a novel, non-oral route of allergen immunotherapy, utilizing the skin and its robust density of epidermal Langerhans cells (LC) for antigen presentation. This space is non-vascularized and impermeable, which limits allergen exposure into the bloodstream but preserves antigen presentation to regional lymph nodes to generate gut-homing regulatory T cells. The EPIT patch utilizes natural water loss from the skin to absorb electrosprayed allergen through condensation. EPIT represents an alternative, non-oral route of immunotherapy for food allergy, with good efficacy and strong safety profiles across multiple phase 2 and 3 studies for milk and peanut. Efficacy appears the best in very young children (1-3 years old), which has been shown to continue to enhance with extended treatment duration up to 36 months. Efficacy in slightly older children ages 4-11 years of age is less clear, but appears to be better in children ages 4-7 years of age. In clinical trials of milk and peanut EPIT, most subjects experienced adverse effects, mainly mild-to-moderate skin reactions localized around the patch placement site, which improve with continued duration of wear. Rates of treatment-related anaphylaxis have been very low across all studies and ages, ranging from 1.6% to 4%, and were lowest in the infant and toddler population. While further studies of safety (1- to 3-year-olds) and efficacy (4- to 7-year-olds) are ongoing, EPIT is a potentially valuable addition to the current landscape of food allergy therapies, in particular for infants and toddlers where families may be seeking a non-oral route of treatment.

Basophil Activation Test for the Improved Diagnosis of Peanut and Tree Nut Allergy

PURPOSE OF REVIEW

As an ex-vivo test of allergic effector cell activation, basophil activation testing (BAT) to allergen enables quantification of the in-vivo IgE-mediated allergic response. BAT thus holds promise in the diagnosis and monitoring of peanut and tree nut allergies. Recent systematic analyses and expert recommendations support a role for BAT in the diagnosis of peanut and tree nut allergy.

RECENT FINDINGS

Diagnostic cut-offs for BAT in peanut and tree nut allergy have been identified. Consistently, BAT can discriminate with high sensitivity and specificity between allergy and tolerance when measured against oral food challenges. Furthermore, the utilization of BAT has can increase the sensitivity and specificity of peanut allergy and tree nut allergy diagnosis, both alone and in conjunction with specific IgE testing and skin prick testing. BAT is a promising tool in the diagnosis of peanut and tree nut allergy.

Pemphigoid disease model systems for clinical translation

Pemphigoid diseases constitute a group of organ-specific autoimmune diseases characterized and caused by autoantibodies targeting autoantigens expressed in the skin and mucous membranes. Current therapeutic options are still based on unspecific immunosuppression that is associated with severe adverse events. Biologics, targeting the IL4-pathway or IgE are expected to change the treatment landscape of pemphigoid diseases. However, clinical studies demonstrated that targeting these pathways alone is most likely not sufficient to meet patient and healthcare partitioners expectations. Hence, model systems are needed to identify and validate novel therapeutic targets in pemphigoid diseases. These include pre-clinical animal models, in vitro and ex vivo model systems, hypothesis-driven drug repurposing, as well as exploitation of real-world-data. In this review, we will highlight the medical need for pemphigoid diseases, and in-depth discuss the advantages and disadvantages of the available pemphigoid disease model systems. Ultimately, we discuss how rapid translation can be achieved for the benefit of the patients.

Immunotherapeutic Approaches to Peanut Allergy Treatment-Pre-Clinical and Clinical Studies: A Comprehensive Review

Peanut allergy is a prevalent and potentially life-threatening condition affecting millions of people worldwide, necessitating strict dietary vigilance. Despite its widespread impact, current treatment options are predominantly limited to allergen avoidance and emergency management of allergic reactions. This review explores contemporary immunotherapeutic strategies aimed at achieving long-term relief for individuals with peanut allergy. We conducted a comprehensive literature review to discuss different treatment approaches, such as subcutaneous immunotherapy (SCIT), epicutaneous immunotherapy (EPIT), oral immunotherapy (OIT), and sublingual immunotherapy (SLIT), focusing on their mechanisms, efficacy, and safety profiles. Additionally, the review delves into novel approaches such as monoclonal antibodies targeting IgE and other critical immune pathways, adjuvanted therapies utilizing nanoparticles and gut microbiota, and advances in adoptive cell therapy including CAR-T cells and regulatory T cells. Furthermore, we highlight some clinical trials that test the efficacy and safety of these novel immunotherapeutic approaches in patients with peanut allergy. Collectively, we provide an overview of advancements in immunotherapeutic interventions for peanut allergy and recommendations for personalized immunotherapy regimens, ultimately paving the way for more effective treatment strategies.

Biologic Therapies for Severe Asthma in School-Age Children

Children with severe asthma incur substantial disease-related morbidity. Despite treatment with inhaled corticosteroids and additional controller medications, many patients continue to experience recurrent exacerbations, impaired lung function, and diminished quality of life. Most children with severe asthma demonstrate evidence of a phenotype consistent with ongoing type 2 inflammation. Fortunately, the advent of biologic therapies, monoclonal antibodies that target specific pathways relevant to asthma pathogenesis, has allowed most children with severe asthma to experience marked improvements in disease control and clinical outcomes. Four biologic medications that target various aspects of type 2 inflammation-specifically omalizumab, mepolizumab, benralizumab, and dupilumab-are currently approved by the United States Food and Drug Administration for use in children 6-11 years of age with specific phenotypes of severe asthma. The selection of the most appropriate biologic for a patient's phenotype is driven by a biomarker-based approach, including assessments of blood eosinophil counts, fraction of exhaled nitric oxide levels, and allergic sensitization and total immunoglobulin E levels. These biologic medications have been demonstrated to significantly reduce the rates of asthma exacerbations between 27% and 59% relative to placebo, although they vary in their impact on lung function. The overall safety profiles of these biologics have been reassuring. This review discusses the role of biologics in childhood asthma, including the strategy for phenotyping patients, summarizes the data supporting the efficacy and safety of biologics in this population, and presents an approach for choosing a biologic and monitoring patient outcomes.

LuLIPLEX: A Fast, Highly Sensitive, and Multiplexed Method for the Detection of IgE Against Major Allergens

BACKGROUND

Diagnosis of allergies is mostly based on the patient's clinical history and allergen provocation tests. Determination of specific IgE (sIgE) profiles can be performed to support allergy diagnosis. This is commonly done in vivo by the skin prick test or in vitro with automated systems. Several platforms exist to quantify sIgE levels, but all these methods require access to specific instruments, often delaying the test's results. The IgE luciferase-linked immunosorbent assay (LuLISA) allows bioluminescent quantification of IgE against peanut in microliter samples, but this method awaits extension to other allergens. This study aimed to validate a new method, named LuLIPLEX, for multiplexed bioluminescent detection of sIgE against 20 major molecular allergens.

METHODS

Quantification of sIgE against 12 recombinant or purified food allergens and eight aeroallergens was performed by LuLIPLEX versus standard IgE detection methods (ImmunoCAP, ISAC, ALEX, or NOVEOS). Multiplexed detection of IgE against these 20 allergens was performed within 45 min using 50 μL of serum, plasma, or whole blood samples.

RESULTS

A head-to-head comparison between LuLIPLEX and standard IgE detection methods showed a high correlation among all allergens tested. sIgE profiles in polysensitized subjects could be determined within 45 min in serum and plasma samples, as well as using a single drop of capillary blood.

CONCLUSIONS

LuLIPLEX is a rapid and sensitive method to quantify sIgE levels against multiple allergens. Given that the test is very fast and can be performed on small and inexpensive luminometers, the IgE LuLIPLEX could allow point-of-care testing of sIgE profiles in allergic subjects.

Peanut Oral Immunotherapy in Children with High-Threshold Peanut Allergy

BACKGROUND

Approved therapeutics for peanut allergy are not designed for the many patients with allergic reactions to more than one peanut.

METHODS

We randomly assigned (1:1) participants 4 to 14 years of age reacting to a challenge of between 443 mg and 5043 mg of peanut protein to peanut oral immunotherapy (P-OIT) using home-measured peanut butter versus peanut avoidance. The primary end point was the difference between groups in the proportion tolerating a two-dose-level increase or 9043 mg of peanut protein. For ingestion participants tolerating 9043 mg, sustained unresponsiveness (tolerance off treatment) was tested after 16 weeks of ad lib ingestion followed by 8 weeks of abstinence.

RESULTS

Of 73 participants, 38 were randomly assigned to P-OIT and 35 to avoidance. Thirty-two of 38 participants in the ingestion group (84.2%) and 30 of 35 in the avoidance group (85.7%) underwent the primary outcome food challenge. The primary analysis with prespecified multiple imputation for missing values showed 100% success for ingestion versus 21.0% for avoidance (between-group difference, 79.0 percentage points; 95% confidence interval [CI], 64.6 to 93.5; P<0.001). All 32 treated and 3 out of 30 avoiders (10%) tolerated 9043 mg. In the intention-to-treat analysis, sustained unresponsiveness occurred in 68.4% (26/38) on P-OIT versus 8.6% (3/35) tolerating 9043 mg among those avoiding (between-group difference, 59.9 percentage points; 95% CI, 42.4 to 77.3). No dosing reactions were greater than grade 1 severity, and no serious adverse events were reported.

CONCLUSIONS

In this trial of P-OIT using store-bought, home-measured peanut versus peanut avoidance in high-threshold peanut allergy, those treated achieved significantly higher rates of desensitization with a durable response off treatment. (Funded by the National Center for Advancing Translational Sciences [UL1TR004419] and the National Institute of Allergy and Infectious [U19AI136053]; ClinicalTrials.gov number, NCT03907397.).

Type 2 immunity in allergic diseases

Significant advancements have been made in understanding the cellular and molecular mechanisms of type 2 immunity in allergic diseases such as asthma, allergic rhinitis, chronic rhinosinusitis, eosinophilic esophagitis (EoE), food and drug allergies, and atopic dermatitis (AD). Type 2 immunity has evolved to protect against parasitic diseases and toxins, plays a role in the expulsion of parasites and larvae from inner tissues to the lumen and outside the body, maintains microbe-rich skin and mucosal epithelial barriers and counterbalances the type 1 immune response and its destructive effects. During the development of a type 2 immune response, an innate immune response initiates starting from epithelial cells and innate lymphoid cells (ILCs), including dendritic cells and macrophages, and translates to adaptive T and B-cell immunity, particularly IgE antibody production. Eosinophils, mast cells and basophils have effects on effector functions. Cytokines from ILC2s and CD4+ helper type 2 (Th2) cells, CD8 + T cells, and NK-T cells, along with myeloid cells, including IL-4, IL-5, IL-9, and IL-13, initiate and sustain allergic inflammation via T cell cells, eosinophils, and ILC2s; promote IgE class switching; and open the epithelial barrier. Epithelial cell activation, alarmin release and barrier dysfunction are key in the development of not only allergic diseases but also many other systemic diseases. Recent biologics targeting the pathways and effector functions of IL4/IL13, IL-5, and IgE have shown promising results for almost all ages, although some patients with severe allergic diseases do not respond to these therapies, highlighting the unmet need for a more detailed and personalized approach.

Food oral immunotherapy

Food oral immunotherapy (OIT) is an option for the treatment of immunoglobin E (IgE)-mediated food allergy that involves administering gradually increasing doses of an allergenic food over time (under medical supervision) with the goal of desensitizing an individual to the food allergen. Current Canadian clinical practice guidelines for OIT recommend this form of therapy as an option in patients with food allergy. The intervention should be prioritized in the infant and toddler population, in which it is particularly well tolerated and can lead to sustained unresponsiveness (also sometimes referred to as remission). In this article, we provide an overview of OIT and discuss the role non-allergist clinicians can play in caring for patients undergoing OIT.

Pearls for practice from the 2023 joint task force anaphylaxis practice parameter

PURPOSE OF REVIEW

To share important highlights on the management of anaphylaxis from the latest 2023 practice parameter.

RECENT FINDINGS

The 2023 Allergy Immunology Joint Task Force on Practice Parameters (JTFPP) anaphylaxis practice parameter provides updated anaphylaxis guidance. Criteria for the diagnosis of anaphylaxis are reviewed. The parameter highlights that while anaphylaxis is not more severe in younger children, age-specific symptoms can vary. Activation of emergency medical services may not be required in patients who experience prompt resolution of symptoms following epinephrine use and caregivers are comfortable with observation. For children weighing <15 kg, the anaphylaxis parameter suggests the clinician may prescribe either the 0.1 mg or the 0.15 mg epinephrine autoinjector, with the 0.3 mg autoinjector prescribed for those weighing 25 kg or greater. In patients with heart disease, discontinuing or changing beta blockers and/or angiotensin converting enzyme inhibitors may pose a larger risk for worsened cardiovascular disease compared with risk for severe anaphylaxis with medication continuation. Furthermore, in patients with a history of perioperative anaphylaxis, shared decision-making based on diagnostic testing and clinical history is recommended prior to repeat anesthesia use. Beyond the recent parameter update, novel contemporary therapies can decrease risk of community anaphylaxis.

SUMMARY

The 2023 JTFPP Anaphylaxis Guidelines offer up-to-date guidance for the diagnosis and management of anaphylaxis in infants, children, and adults.

Roads to remission: evolving treatment concepts in type 2 inflammatory diseases

Non-communicable diseases (NCDs) characterised by type 2 inflammation, including asthma, allergic rhinitis, chronic rhinosinusitis with nasal polyps, atopic dermatitis, food allergies and eosinophilic esophagitis, are increasing in prevalence worldwide. Currently, there is a major paradigm shift in the management of these diseases, towards the concept of disease modification and the treatment goal remission, regardless of severity and age. Remission as a treatment goal in chronic inflammatory NCDs was first introduced in rheumatoid arthritis, and then adopted in other non-type 2 inflammatory diseases. Among diseases with type 2 Inflammation, this concept is novel and currently most advanced in asthma. This new paradigm has been developed based on a better understanding of the pathophysiology of type 2 inflammation and the advent of highly effective drugs selectively interfering with type 2 pathways. Here, we review the evolution of the new remission concepts in type 2 inflammatory diseases and discuss associated challenges and future research needs.

Funding

None.

ADP101 multifood oral immunotherapy for food-allergic patients: Harmony phase 1/2 randomized clinical trial

Background

Oral immunotherapy is an established approach to desensitize the immune system in the context of allergic disease; however, the only currently approved product is for peanut allergy. ADP101 is a novel, pharmaceutical-grade, multifood oral immunotherapy in development to simultaneously treat single or multiple food allergies, containing allergenic proteins from 15 foods in equal parts by protein weight.

Objective

The phase 1/2 Harmony trial (NCT04856865) evaluated efficacy and safety of ADP101 in participants with qualifying allergy to 1 to 5 foods in ADP101, defined as dose-limiting symptoms with a ≤100 mg challenge dose during double-blind, placebo-controlled food challenge (DBPCFC).

Methods

Participants were randomized to low-dose (1500 mg/d; 100 mg protein per food) or high-dose (4500 mg/d; 300 mg protein per food) ADP101, or matched placebo, with dose escalation followed by daily maintenance dosing over 40 weeks. The primary endpoint was the proportion of participants tolerating a ≥600 mg challenge dose of a single qualifying food without dose-limiting symptoms at the Week 40 Exit DBPCFC (ie, responders).

Results

In the primary analysis population (61 pediatric participants aged 4-17 years), a greater response rate was observed in both the high-dose ADP101 (55.0%) and low-dose ADP101 (38.1%) groups compared with pooled placebo (20.0%) (nominal P = .048, P = .306, respectively; adjusted for multiple comparisons, P = .097, P = .306, respectively). Desensitization to ≥2 foods was observed in individuals with multiple food allergies, as was desensitization at levels over 600 mg. ADP101-treated participants showed an overall reduction in skin-prick test reactivity, with an increase in maximum tolerated dose across the majority of foods tested. Adverse events were mostly mild or moderate, with no life-threatening events or deaths.

Conclusions

The study did not meet its primary endpoint, but ADP101 demonstrated a favorable safety profile and increased the reactive threshold in DBPCFC in pediatric participants with single or multiple food allergies across multiple endpoints, warranting further clinical investigation.

Management of children with food allergies by allergists in the United States

Background

Management of patients with food allergies is complex, especially in cases of patients with multiple and potentially severe food allergies. Although international guidelines exist for food allergy management, the role of the allergist in the decision-making process is key.

Objective

Our aim was to investigate the management patterns and educational needs of practicing allergists treating patients with food allergies.

Methods

An online survey was e-mailed to United States-based practicing allergists (N = 2833) in November-December 2021. The allergists were screened for managing 1 or more patients (including ≥25% pediatric patients) with food allergies per month. The allergists responded to questions regarding food allergy management in response to 2 hypothetical pediatric case studies, their familiarity with available guidelines and emerging treatments, and their future educational preferences. A descriptive analysis of outcomes was conducted.

Results

A total of 125 responding allergists (4.4%) met the eligibility criteria and completed the survey. The allergists prioritized written exposure action plans, patient-caregiver communication, prevention of serious reactions, and consideration of both food allergy severity and allergic comorbidities in the management of patients with food allergies. With regard to recommending biologics in the future, the allergists identified patient history of anaphylaxis and hospitalizations, food allergy severity, and allergic comorbidities as all being important factors to consider when deciding on appropriate treatment options. The allergists noted their ongoing educational needs, especially for current and emerging treatments for food allergies.

Conclusion

With the treatment landscape for food allergies evolving rapidly, the decision-making priorities and continuing educational needs of allergists will be important in optimizing the management of patients with food allergies.

Severe Asthma in School-Age Children: An Updated Appraisal on Biological Options and Challenges in This Age Group

This review examines the growing role of biological therapies in managing severe asthma in children aged 6-11 years. Severe asthma, characterized by persistent symptoms and frequent exacerbations, presents significant challenges in pediatric care. Biologic treatments, including mepolizumab, omalizumab, and dupilumab, provide targeted interventions for patients with high eosinophilic inflammation or allergic asthma (T2-high asthma). Alongside their therapeutic benefits, the review evaluates the safety profiles of these biologics, highlighting potential side effects and the necessity for monitoring during long-term use. Cost considerations and treatment adherence also emerge as important challenges that need to be addressed in clinical practice. Additionally, the review emphasizes the need for identifying patients who would derive the most benefit from biologic therapies, advocating for the development of biomarkers to aid in treatment decisions. Emerging biologics, such as tezepelumab, are introduced as promising alternatives with the potential to target upstream inflammatory pathways, offering hope for treating T2-low asthma forms, which currently lack effective treatment options in children.

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.