Box 5: Recommendations regarding contraindications	Ethical imperative, data or other considerations in support of the recommendation Level of evidence (applicable when recommendations are based on outcome data from clinical studies)
Previous history of anaphylaxis to the targeted food is not a contraindication for OIT	This recommendation is based on the principle of equity in eligibility It is supported by a large amount of clinical evidence A history of anaphylactic reactions to the targeted food allergen was generally not an exclusion criterion in OIT studies. Some RCTs [43, 46, 47, 49, 59, 63] and clinical practice case series [30] excluded patients with a history of severe anaphylaxis; others included them (RCTs [41, 61, 64]; case series [29, 40]). Evidence from large case series on whether baseline history of anaphylaxis had an impact on OIT outcomes is inconsistent [32, 40, 53, 54], but most patients with a history of anaphylaxis were able to achieve at least partial desensitization [32, 40]. This is coherent with data from consultations. Level of evidence: HIGH
Multiple food allergies are not a contraindication to OIT	This recommendation is based on the principle of equity in eligibility It is supported by a moderate amount of consistent clinical evidence from two case series (N = 111 and N = 280; moderate risk of bias [IHE tool] [32, 54]) and additional clinical studies targeted towards patients with multiple food allergies [68–71]. Level of evidence: MODERATE
Uncontrolled asthma is an absolute contraindication to OIT. Asthma must be controlled before beginning OIT and pro-actively managed during OIT	This recommendation is based on the principle of nonmaleficence In many RCTs [31, 39, 41, 43, 46, 47, 60, 61] and clinical practice case series [30, 32, 54], severe and/or poorly controlled or unstable asthma was an exclusion criterion for OIT. However, most patients with controlled asthma were able to achieve at least partial desensitization [33, 40, 54, 72]. This is coherent with data from consultations. Level of evidence: HIGH
Pregnancy is an absolute contraindication for initiating OIT	This recommendation is based on the principle of nonmaleficence It is in line with the current general standard of care in allergen immunotherapy
Conditions such as active severe atopic dermatitis, pre-existing eosinophilic esophagitis, heart disease, and those requiring the use of beta-blockers or ACE inhibitors are relative contraindications for OIT. A decision to pursue OIT in these patients should be based on clinical judgment, provider expertise and shared decision-making	This recommendation is based on the principles of nonmaleficence, equity of eligibility and patient autonomy It is in line with the current general standard of care in allergen immunotherapy
Patient- or caregiver-specific contexts that may jeopardize the safe administration of therapy must be assessed. These include but are not limited to unreliable adherence to protocol, reluctance to use epinephrine, language barrier, severe anxiety, psychiatric barriers, non-collaborative family dynamics, lack of schedule flexibility for proper dosing, and lack of commitment from patient or caregivers. If these cannot be satisfactorily addressed, they constitute contraindications for OIT	This recommendation is based on the principle of patient protection It is supported by data from consultations with stakeholders