New insights into food allergy and anaphylaxis management

We are kicking off this issue with a discussion on how to select patients for different food allergy therapies. The landscape of food allergy has changed tremendously over the past few years, including not only two U.S. Food and Drug Administration approved therapies (oral peanut immunotherapy and omalizumab for the treatment of single and/or multiple food allergies) currently available for individuals with food allergy but many novel treatments in development as well. When selecting patients for therapy, important factors to consider include, at a minimum, eligibility, age, type of food trigger, history of life-threatening reactions, baseline quality of life, and presence of atopic comorbidities.¹ Patients have a say in their choice of therapy and avoidance remains an acceptable strategy for those who choose to do so.

Mustafa and Sokol² address the efficacy of omalizumab for the management of food allergy, both as monotherapy and in conjunction with oral immunotherapy. Omalizumab is currently approved for the management of immunoglobulin E (IgE) mediated food allergy in individuals ≥1 year of age, after results from the Omalizumab as Monotherapy and as Adjunct Therapy to Multi-Allergen OIT in Food Allergic Participants (OUtMATCH) study,³ which demonstrated that omalizumab increases the threshold dose of multiple food allergens needed to elicit an allergic reaction. However, despite the demonstrated efficacy in food allergy and favorable safety profile, many questions remain, including identifying who is the ideal patient for omalizumab, determining the role of oral food challenges before and during therapy, evaluating food allergy tolerance while on treatment, and optimizing the cost-effectiveness of omalizumab for food allergy. There is limited knowledge with regard to the real-world impact on food allergy–related quality of life.

Peanut sublingual immunotherapy (SLIT) is reviewed by Chagarlamudi et al.⁴ Studies demonstrated significant increases in the reaction threshold after therapy, with mild adverse effects, such as transient oropharyngeal pruritus, which is most commonly reported.⁴ Severe symptoms that required treatment with epinephrine have generally been rare occurrences during SLIT, reflecting a reassuring safety profile.⁴ Adherence to SLIT may be an issue because withdrawal from therapy is shown to be common, especially in older participants.

The next article, by Mack,⁵ examines the intricate interplay between food allergy and asthma. Although asthma is a prevalent comorbidity in food allergy, its impact on food allergy outcomes is not yet fully understood. It has been well established that a higher prevalence of asthma among individuals who experienced fatal anaphylaxis, yet there is no consistent evidence that supports a direct causal link between food allergy and the development of asthma. Clinicians and patients often overestimate asthma control, which leads to underestimated risks associated with severe allergic reactions. The authors underscore the critical need for optimal asthma control before and during oral food challenges and food allergy therapies, highlighting the heightened risk of severe reactions in individuals with poorly controlled asthma. Although biologics such as omalizumab show promise in enhancing asthma control and increasing food allergy thresholds, a comprehensive, multifaceted approach that involves diligent asthma management, patient education, and appropriate treatment strategies is essential for ensuring safe and effective management of food allergy in the context of asthma. The authors conclude that integrated management when addressing both conditions concurrently is vital for improving patient safety and quality of life.

Next, Shaker et al.⁶ dive into our understanding of risk within the context of thresholds of reactivity. Food allergy thresholds and reaction severity can vary, but both tend toward stability, at least in the short term. Thresholds can assist us in improving food allergy management. They also have the potential to better leverage active food allergy therapies as well as tailor most appropriate avoidance, in selected individuals. The authors emphasize that shared decision-making is central to operationalizing food allergen thresholds in daily clinical practice.

Herbert et al.⁷ examine caregivers' daily food allergy management behaviors, such as identifying safe foods and epinephrine availability in a total of 83 primary caregivers of young children diagnosed with an IgE-mediated food allergy. The authors report that there was frequent epinephrine availability, but infrequent use of behaviors that verify foods as allergen-free when the food is ingested. This approach may place children at risk of allergic reactions and indicates a need for clinician education on food safety decision-making. The study’s findings highlight the need for support for primary caregivers, who are preparing the majority of children's meals and/or snacks, and education and/or policy for daycare and/or schools where many meals are ingested.

The topic of infant anaphylaxis remains at the forefront of our specialty.⁸ The true prevalence of infant anaphylaxis is unknown, but such cases may be increasing in presentation to emergency departments, with studies⁸ that evaluate health-care utilization after implementation of early introduction guidelines that report an increase in the use of the emergency department for food-related visits as well as an increase in epinephrine prescriptions for infants. Reasons for these increases may include early food introduction as well as therapeutic interventions such as early life or preschool oral immunotherapy. Infant anaphylaxis presents many diagnostic challenges, including poor recognition attributable to confusing signs and symptoms that may be age-specific, and risk for inadequate acute management. Education of health-care professionals is key to recognize and treat anaphylaxis effectively and timely.

Finally, Hatcher and Adams⁹ provide valuable insight into the evaluation of patients with food-related concerns who are interested in military service. The authors discuss current military medical standards and diagnostic protocols related to food allergies in recruitment and enlistment, the appropriate identification of food reactions that may impact candidacy for military accession, and provide strategies to address the food-related condition and help navigate the military medical evaluation process. Through review of Department of Defense medical standard guidelines⁹ as well as some service-specific initiatives to expand accessions, allergists can systematically steer through the evaluation process to support military applicants clearing the path for accession.

I hope you enjoyed the challenging topics discussed in this summer issue of the Journal of Food Allergy and found them useful to your practice. I wish you all a wonderful and enjoyable summer!