Improving the safety of oral immunotherapy for food allergy

Abstract

Food allergy is a major public health problem in children, impacting upon the affected individual, their families and others charged with their care, for example educational establishments, and the food industry. In contrast to most other paediatric diseases, there is no established cure: current management is based upon dietary avoidance and the provision of rescue medication in the event of accidental reactions, which are common. This strategy has significant limitations and impacts adversely on health‐related quality of life. In the last decade, research into disease‐modifying treatments for food allergy has emerged, predominantly for peanut, egg and cow's milk. Most studies have used the oral route (oral immunotherapy, OIT), in which increasing amounts of allergen are given over weeks–months. OIT has proven effective to induce immune modulation and ‘desensitization’ – that is, an increase in the amount of food allergen that can be consumed, so long as regular (typically daily) doses are continued. However, its ability to induce permanent tolerance once ongoing exposure has stopped seems limited. Additionally, the short‐ and long‐term safety of OIT is often poorly reported, raising concerns about its implementation in routine practice. Most patients experience allergic reactions and, although generally mild, severe reactions have occurred. Long‐term adherence is unclear, which rises concerns given the low rates of long‐term tolerance induction. Current research focuses on improving current limitations, especially safety. Strategies include alternative routes (sublingual, epicutaneous), modified hypoallergenic products and adjuvants (anti‐IgE, pre‐/probiotics). Biomarkers of safe/successful OIT are also under investigation.

Extended boiling of peanut progressively reduces IgE allergenicity while retaining T cell reactivity

“…A hypoallergenic food allergen has the potential to initiate desensitization with fewer adverse events [39]. We investigated if extended boiling could produce a hypoallergenic peanut suitable for OIT.…”

IL-9-producing cells in the development of IgE-mediated food allergy

“…Food immunotherapy can induce some degree of desensitization and provide protection in a majority of children with egg and milk allergy by raising the reaction threshold [4]. However, the initial benefits of the protection sometimes wear off, and some individuals develop severe adverse responses to the therapy, particularly the GI symptoms [4, 10]. The goal of food immunotherapy in developing sustained unresponsiveness and eventually tolerance to causal foods has not been achieved for clinical practice.…”

Safety and Efficacy of Low-Dose Oral Immunotherapy for Hen's Egg Allergy in Children

“…A high efficacy of desensitization in response to oral immunotherapy (OIT) has been reported [4]; however, unresponsiveness and tolerance are not easily achieved, and moderate to severe symptoms sometimes occur [4,5,6]. Therefore, long-term treatment methods with a higher level of safety are desired [6].…”

“…Therefore, long-term treatment methods with a higher level of safety are desired [6]. Currently, the most commonly used target dose for OIT against hen's egg allergy is 1 whole egg [4,5,7].…”