Abstract
Oral immunotherapy is proposed as the only active intervention to modify allergies and decrease the risk of severe reactions. However, it is crucial to note that oral immunotherapy still presents a notable failure rate and potential for severe, life-threatening outcomes. Notably, patients who discontinue oral immunotherapy may face an increased risk of fatal reactions. Omalizumab could be a viable option for patients with failed oral immunotherapy.
Keywords: Fatal anaphylaxis, Oral immunotherapy, Failed immunotherapy, Omalizumab
Main text
Dear Editor,
We appreciate the paper by Novembre et al. [1], nicely and detailing discussing risk factors for fatal anaphylaxis, however we suggest that a relevant issue has been overlooked.
As outlined, oral immunotherapy (OIT) is currently the only active intervention that can alter the course of allergies and reduce the risk of severe anaphylaxis. However, as accurately noted by the authors, OIT still carries a significant risk of failure (approximately 20%) and can result in rare, yet severe and life-threatening reactions.
We remind that the potential for severe reactions is particularly high in those who have not successfully completed OIT and may encounter the allergen unintentionally. In this regard, we mention a study [2] in which the risk of life-threatening reactions was 3.5% in the group of patients continuing milk during OIT, compared to 6.3% in the group who had stopped treatment.
Remarkably in the latter group fatal reactions were also reported. The worrisome speculation may be that in these patients failed OIT may paradoxically act as booster. This issue is particularly relevant for adolescents, who already are at high risk, for their behaviors and outdoors life.
Moreover, we suggest that in these highly selected patients Omalizumab could be considered, as shown by a study [3] conducted on few patients, which had previously failed immunotherapy, successfully treated with omalizumab and a restart of OIT. No patients experienced severe reactions, even after omalizumab discontinuation and all increased tolerance threshold.
In conclusion, we remark that patients with failed OIT may represent a population at higher risk of fatal anaphylaxis, deserving the proposal of an Omalizumab protected OIT restart.
Acknowledgements
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Abbreviation
- OIT
Oral immunotherapy
Authors’ contributions
FN and FC wrote the first draft of the manuscript. LB, IB and EB critically reviewed the manuscript. All the authors read and approved the final version of the manuscript as submitted.
Funding
Authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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Competing interests
The authors have no conflicts of interest to declare. All co-authors have seen and agree with the contents of the manuscript and there is no financial interests to report.
Footnotes
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References
- 1.Elio Novembre et al. Fatal food anaphylaxis in adults and children. 2024. 10.1186/s13052-024-01608-x. [DOI] [PMC free article] [PubMed]
- 2.Badina et al. Life-threatening anaphylaxis in children with cow’s milk allergy during oral immunotherapy and after treatment failure. 2022. 10.1002/iid3.607. [DOI] [PMC free article] [PubMed]
- 3.Badina et al. Omalizumab effectiveness in patients with a previously failed oral immunotherapy for severe milk allergy. 2021. 10.1002/iid3.542. [DOI] [PMC free article] [PubMed]
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