Table 1.

Round 2 Delphi exercise

Statement	Appropriateness, median	Disagreement index (DI)
Individuals with pollen-food allergy syndrome (PFAS) may benefit from education about the mechanistic basis of their PFAS.	9	0
Reactions in PFAS are mostly benign, and limited to the oropharynx, although, rarely, more severe symptoms may occur.	9	0.050
Certain foods associated with PFAS (nuts, soy milk, smoothies/fresh juices), especially if consumed rapidly or in large amounts might rarely trigger systemic symptoms.	9	0.132
Certain factors have been reported to increase the severity of PFAS symptoms including medications (e.g., PPIs, NSAIDs), bariatric surgery, uncontrolled asthma, fasting, and exercise)	8	0.132
Individuals with PFAS limited to oral symptoms may choose to avoid only the raw forms of the responsible fruit/vegetable.	9	0.132
Patients with PFAS limited to oral symptoms may choose to continue to ingest the responsible fruit and vegetable if well-cooked but cautioned that roasting may not eliminate the risk of reaction with nuts.	9	0.132
Lighter cooking methods (e.g., steaming or stir-frying) may be insufficient to fully denature the allergens relevant to PFAS.	8	0.132
Patients should be educated on the higher allergen contents in the peels and seeds of fruits but cautioned peeling and removing the seeds is usually insufficient to prevent symptoms of PFAS.	9	0.132
Patients with PFAS characterized by systemic reactions (i.e., symptoms extending beyond the oropharynx) should strictly avoid the responsible fruits and vegetables.	9	0.132
When possible, modifiable risk factors for systemic reactions should be identified and mitigated in patients with PFAS to decrease the risk of life-threatening anaphylaxis.	9	0
Mild symptoms of PFAS limited to oropharynx often resolve without treatment; a non-sedating antihistamine can be used for uncomfortable symptoms.	9	0
PFAS with a history of systemic reaction (defined as having symptoms that extend beyond the oropharynx) may be at a higher risk for future severe reactions. An emergency treatment plan and a prescription of epinephrine autoinjector (EAI) should be offered.	9	0
Individuals with PFAS limited to the oropharynx and who have risk factors for systemic reactions (PPI or beta-blockers use, gastric bypass surgery, or asthma) benefit from a shared decision-making approach when discussing the need for an epinephrine autoinjector (EAI).	9	0.132
Pollen allergen immunotherapy (AIT) via subcutaneous or sublingual route is not proven to alleviate symptoms of PFAS. PFAS is not an indication for pollen AIT.	9	0.132