Persistent allergic respiratory symptoms induced by food allergy: Report of two cases

Case report Dust is a known mixture and carrier of multiple allergens and an epidemiologic study demonstrated the presence of peanut proteins in school cafeterias and classrooms, suggesting that schools may play an important role in exposure to environmental food allergens. While inhalation of food allergens is a known trigger of IgE-mediate acute respiratory reaction as rhinitis and wheezing, little is known about persistent allergic asthma and/or rhinitis induced by chronic inhalation of food allergens. Here we report two cases of teenagers with nuts allergy presenting with persistent respiratory symptoms when exposed to closed and dusty environments. The first case concerns a 12-year-old boy allergic to walnut and hazelnut (specific IgE > 100 and 81.70 kU/l, respectively). For some years he has had a persistent mild asthma, frequent nasal occlusion and rhinorrhea, without any allergic sensitization to aeroallergens. Symptoms occurred exclusively during school period when he required maintenance therapy with inhaled and nasal steroids. He was asymptomatic and did not need any treatment during summer. During the lockdown period due to Covid-19 pandemic, he did not attend school for several months and he was able to discontinue inhaled corticosteroid therapy without recurrence of asthma and rhinitis symptoms. Asthma recurred after he returned to school, but with only mild intermittent symptoms, probably thanks to the use of masks and the frequent airing of the classrooms. On a single occasion he experienced nasal occlusion and rhinorrhea after that a parent had eaten hazelnut cream in the same room where he was. The second case deals with a 17-year-old boy with a history of several food allergies (milk, egg, wheat, banana, nuts, hazelnuts) and mild persistent asthma in absence of sensitization to aeroallergens. He successfully underwent oral desensitization for milk, egg and wheat in previous years. Asthma symptoms improved over the years together with progressive development of oral tolerance to food allergens for which oral immunotherapy had been done. On the other hand, he referred persistence of allergic rhinitis especially during the school year and his symptoms got worse in classroom. Exhaled nitric oxide was quite increased with evidence of eosinophils in nasal smears. In-vitro and in-vivo tests only detected food allergens sensitizations, in particolar to walnuts and hazelnuts (specific IgE were 61.00 and 55.50 kU/l respectively). These two clinical cases suggest that food allergens might be causative agents of allergic persistent asthma and/or rhinitis as aeroallergens do.

Value-Based, Cost-Effective Care: The Role of the Allergist-Immunologist.

Asthma and allergic disease impact millions of patients and are associated with high costs. Up to 30% of all medical care involves wasted spending. Across the spectrum of care provided by the allergist-immunologist, there are opportunities to improve value and reduce medical waste. Several examples highlight this reality. Evidence suggests that most patients may receive cost-effective care in the management of chronic spontaneous urticaria without the need for laboratory testing. For patients with asthma, although a single maintenance and reliever therapy approach may be cost-effective, insurance-mandated therapy changes are not, and may harm patients. Biologics may be very effective in improving asthma control but are too expensive for this indication-as demonstrated by cost-effectiveness analyses and highlighted by the Institute of Clinical and Economic Review, which concluded that the value-based price for asthma biologics ranges between $6500 and 14,3000 per year. Early introduction may prevent food allergy, but screening before first introduction is neither necessary nor cost-effective, although early salvage food oral immunotherapy may result in improved quality of life and cost savings. Evidence does not support the presence of allergic disease as a risk factor for anaphylaxis to coronavirus disease 2019 vaccination, and risk-stratified vaccination approaches do not appear cost-effective. Allergen immunotherapy is a very cost-effective treatment option. The practice of allergy-immunology has continued to evolve in recent years and can provide a leading example of high-value practice.

Efficacy and safety of baked milk oral immunotherapy in children with severe milk allergy: A randomized, double-blind, placebo-controlled phase 2 trial.

BACKGROUND: Cow's milk allergy is the most common food allergy in young children and has no current treatment. Oral immunotherapy studies to date have shown efficacy but high rates of adverse reactions. OBJECTIVE: We sought to evaluate the safety and efficacy of baked milk oral immunotherapy (BMOIT) in children allergic to baked milk. METHODS: Participants (3-18 years) were randomized to receive BMOIT or placebo for 12 months. Efficacy was assessed by double-blind placebo-controlled food challenge after 12 months of treatment. Safety, quality of life, and mechanistic parameters were also evaluated. RESULTS: Eleven of 15 (73%) BMOIT participants reached the primary end point, tolerating 4044 mg of baked milk protein after 12 months of oral immunotherapy, compared with 0 of 15 (0%) on placebo. The median maximum tolerated dose and median change from baseline was significantly higher in the BMOIT group than in the placebo group (median maximum tolerated dose, 4044 mg vs 144 mg; P = .001; median change in maximum tolerated dose of 3900 mg vs 0 mg, P = .0001). Dose-related reactions were common, but more than 95% in both groups were mild. There was no significant change in cow's milk- or beta lactoglobulin-IgE from baseline for either group. Cow's milk-sIgG4 did significantly increase and casein IgE decreased in the BMOIT group. For proxy-reported food allergy quality of life, there was a significant difference in the emotional impact domain only, with more improving while on placebo compared with BMOIT. Most children and adolescents in the BMOIT group directly reported improvement in at least 1 domain. CONCLUSIONS: BMOIT was well tolerated and induced a substantial level of desensitization after 12 months of treatment.

OUTCOMES OF PEANUT ORAL IMMUNOTHERAPY IN AN ALLERGY CLINIC

Introduction: A single tertiary care center has offered oral immunotherapy (OIT) as a clinical service since 2018 using commercial products and subsequently has offered FDA-approved Peanut (Arachis- hypogaea) Allergen Powder-dnfp (PNAP) since July 2020. Shared decision making regarding OIT was based on previous IgE testing, history, and family preference. Methods: A retrospective chart review was performed in REDCap database. Results: A total of 37 patients initiated OIT (21 commercial products and 16 PNAP). The mean age was 9.25 for commercial product and 7.25 for PNAP with more males than females participating. Co-morbid conditions included allergic rhinitis, asthma, and eczema. Mean peanut IgE prior to starting was 49.75 and Ara h2 was 32.73. Prior reactions to peanut included skin, GI and anaphylaxis. Three children failed an oral challenge prior to starting OIT. There were 5 children that had never ingested peanuts but completed OIT. Minor intermittent side effects including stomach upset and itchy mouth were reported during escalation of both products. Dose adjustment was required for 1 PNAP patient for complaint of dysphagia and pain. There were 4 patients who dropped out of OIT: refusal to eat (1), unrelated GI disease (1) and the COVID-19 pandemic (2). All patients upon reaching maintenance are daily dosing with peanuts or chocolate-covered peanut candy. Lifestyle changes reported since reaching maintenance include eating in restaurants previously avoided and ingesting foods with labels stating: “may contain peanuts,” and “foods processed in a facility with peanuts.” Conclusions: Peanut OIT is safe and well tolerated in our patient population.

REAL-WORLD PERSPECTIVES OF HEALTH CARE PROVIDERS DELIVERING THE FIRST APPROVED TREATMENT FOR PEANUT ALLERGY

Introduction: In January 2020, Peanut (Arachis hypogaea) Allergen Powder-dnfp (PTAH) became the first treatment for Peanut Allergy (PA) approved by the US Food and Drug Administration (FDA). The adoption of innovative new therapies requires consideration of the skills, logistics and practicalities required for implementation. Methods: Qualitative interviews were conducted to explore health care providers’ (HCPs) experiences of delivering PTAH, challenges encountered, and successful implementation strategies. HCPs who had initiated PTAH treatment with ≥3 patients since FDA approval were eligible. Semi-structured interviews were conducted via videoconference. Interviews were audio-recorded, transcribed, and analyzed using content analysis. The study was exempted by the Western Institutional Review Board. Results: Eight allergists and three nurse practitioners participated. Their experiences are characterized by four key themes: 1. factors influencing adoption, 2. factors related to delivering the treatment in everyday practice, 3. learnings and reflections, and 4. delivering PTAH during the COVID-19 pandemic. HCPs described how successful implementation of PTAH requires them to be thoughtful about their clinic’s abilities to integrate complex, time-consuming treatments into their practice. Prior experience of oral immunotherapy was deemed beneficial, but not essential for implementation and learning from others’ experience was suggested as a way of helping new prescribers overcome perceived and actual implementation challenges. Conclusion: The experiences described by the treatment pioneers included in this research serve to benefit the wider allergy community by providing practical solutions, successful implementation strategies and opportunities to share information as new innovative treatments become available to patients.

Elevated Cow's Milk-Specific IgE Levels Prior to Oral Immunotherapy Decrease the Likelihood of Reaching the Maintenance Dose.

BACKGROUND: Food desensitization via oral immunotherapy (OIT) is gaining acceptance in clinical practice. Owing to adverse reactions, the duration of the buildup phase until a maintenance dose is achieved may be prolonged, and in a minority of cases, OIT is stopped. OBJECTIVE: We aimed to assess factors associated with the probability of reaching the maintenance dose in cow's milk (CM) OIT. METHODS: We collected data from patients undergoing CM OIT at the Montreal Children's Hospital, BC Children's Hospital, and Hospital for Sick Children. We compared univariable and multivariable Cox regressions to evaluate sociodemographic factors, comorbidities, clinical characteristics, and biomarkers at study entry associated with the likelihood of reaching a maintenance dose of 200 mL of CM. RESULTS: Among 69 children who reached 4 mL of milk, the median age was 12 years (interquartile range, 9-15 years); 59% were male. Median duration of buildup phase from 4 to 200 mL was 24.0 weeks (interquartile range, 17.7-33.4 weeks). After adjusting for age and sex, higher baseline levels of specific IgE antibodies for α-lactalbumin (hazard ratio [HR] = 0.80; 95% confidence interval [CI], 0.67-0.95), ß-lactoglobulin (HR = 0.86; 95% CI, 0.76-0.98), casein (HR = 0.82; 95% CI, 0.72-0.94), and total CM (HR = 0.79; 95% CI, 0.65-0.97) were associated with a decreased probability of reaching maintenance. In addition, for every 10-mL increase in CM tolerated at entry challenge, the probability of reaching maintenance increased by 10%. CONCLUSIONS: The data suggest that higher levels of CM-specific IgE decreased the likelihood of reaching maintenance, whereas an increased cumulative CM dose at entry challenge increased the likelihood. Assessing these factors before therapy may assist in predicting the success of CM OIT.

Caregiver and allergist views on virtual management of food allergy: A mixed methods study

Background: The COVID-19 pandemic resulted in an abrupt and unanticipated shift to health care delivery, including a transition from in-person to virtual physician encounters. To date, few studies have examined patient and physician views on virtual food allergy management. To this end, we sought to examine caregivers' and allergists' views on virtual allergy care of food allergy. Method: In an embedded mixed-methods study of Canadian caregivers of children (<18 years) and allergists, we collected quantitative and qualitative data on levels of satisfaction and comfort with virtual care (both on a scale of 0-100) and perceived advantages and disadvantages, respectively. Data were collected from October-December 2020. Quantitative data were analyzed descriptively. Qualitative data were analyzed thematically. Findings were integrated in the interpretation. Results: In total, 66 caregivers and 11 allergists participated. Quantitatively, caregiver satisfaction was high and comparable, regardless of type of care, or type of delivery (virtual vs other). In comparison, allergists' satisfaction was lowest for virtual oral food challenge (OFC) and oral immunotherapy (OIT) (mean 40.8 ± 39.7, and 30.2 ± 34.5, respectively;both p < 0.05 vs. initial assessments). Qualitatively, both caregivers and allergists described virtual care as having benefit without the burdens. Qualitative disadvantages of virtual care were, for caregivers, isolation;and, for allergists, limited opportunities for testing and unclear projected utilization of virtual care post-COVID. Conclusion: Caregiver satisfaction was consistently high, although isolation exacerbated by virtual care and more generally, the food allergy itself, remained a concern. Allergist satisfaction was more variable, with preference towards types of care involving less patient risk.

Progress of Home-Based Food Allergy Treatment during the Coronavirus Disease Pandemic in Japan: A Cross-Sectional Multicenter Survey.

The coronavirus disease 2019 (COVID-19) pandemic's impact on food allergy treatment such as home-based oral immunotherapy (OIT) is not known. This cross-sectional, questionnaire-based anonymized survey screened 2500 parents of children with allergic diseases and was conducted in the pediatric outpatient clinics of 24 hospitals. Basic clinical data of the children were collected along with the degree of allergy control, parental anxiety about emergency visits, and the risk of COVID-19 in the first state of emergency. A total of 2439 (97.6%) questionnaires were collected, and 1315 parents who were instructed to initiate home-based OIT for their children were enrolled (OIT group). Subjective OIT progress compared to before the COVID-19 pandemic was ascertained as "Full", "Middle", "Low", "Little", and "Stop" in 264 (20.1%), 408 (31.0%), 384 (29.2%), 203 (15.4%), and 56 (4.3%) participants, respectively. Anxiety about emergency visits and the risk of COVID-19 were negatively associated with the subjective OIT progress. In Japan, approximately half of the children continued smoothly the home-based OIT during the COVID-19 pandemic. Parents with high levels of anxiety about the disruption of the medical care system due to COVID-19 and the risk of COVID-19 did not experience a smooth continuation of home-based OIT.

White paper on peanut allergy - part 1: Epidemiology, burden of disease, health economic aspects.

Peanuts are Leguminosae, commonly known as the legume or pea family, and peanut allergy is among the most common food allergies and the most common cause of fatal food reactions and anaphylaxis. The prevalence of peanut allergy increased 3.5-fold over the past two decades reaching 1.4-2% in Europe and the United States. The reasons for this increase in prevalence are likely multifaceted. Sensitization via the skin appears to be associated with the development of peanut allergy and atopic eczema in infancy is associated with a high risk of developing peanut allergy. Until recently, the only possible management strategy for peanut allergy was strict allergen avoidance and emergency treatment including adrenaline auto-injector in cases of accidental exposure and reaction. This paper discusses the various factors that impact the risks of peanut allergy and the burden of self-management on peanut-allergic children and their caregivers.

Managing food allergy immunotherapy in children during the COVID-19 pandemic.

Food allergy immunotherapy is a promising allergen-specific approach to manage food allergy in children, although it is not exempt from adverse events, even severe. The adverse events are not predictable and furthermore cofactors can play a role in triggering them. During the COVID-19 pandemic, patients on food allergy immunotherapy should be provided with suggestions on how to proceed in the event of COVID-19 infection occurring or is suspected. These recommendations would be of support to clinical practitioners dealing with patients on food allergy immunotherapy since there is little data in the literature on the topic.

[Impact of confinement on the follow-up of oral immunotherapies: A multicentre study in the Île-de-France region]. / Impact du confinement sur le suivi des immunothérapies orales alimentaires : étude multicentrique dans 3 centres d'Île-de-France.

PURPOSE OF THE STUDY: Several studies have confirmed the impact of confinement on the population, resulting in disruption of care, somatic and psychological effects. Our study looks at adverse effects and problems of adherence to oral immunotherapy therapy (OIT) during this period. PATIENTS AND METHODS: A total of 132 patients, mostly children (95%), with an atopic history (60%) followed for an OIT were included in 3 allergology centers in Île-de-France, during the period of confinement from 03/16 to 05/11/20. The main food allergens used for OIT were peanut (38%), cow's milk (24%), hazelnut (14%), egg (9%), cashew nut and pistachio nut (8%). RESULTS: Adverse effects were found in 13 patients or 10% of the cases. These reactions were mainly grade 1 and 2 according to the Ring and Messmer classification. Three patients had grade 3 reactions and six patients used epinephrine at home. Adherence was correct in 81% of cases with no omissions. Three patients increased their daily dose without medical advice. No significant difference was found in the subgroup analysis comparing age-matched children followed up in OIT in 2019 and 2020 over the same period in the same hospital. CONCLUSION: There was no increase in adverse events in OIT during the confinement period. Therapeutic education during OIT is paramount and helps to reduce the occurrence of adverse events.

Novel Approaches to Food Allergy Management During COVID-19 Inspire Long-Term Change.

The SARS-CoV2 pandemic has prompted a re-evaluation of our current practice of medicine. The seemingly abrupt worldwide spread of this disease resulted in immediate changes and a reduction in many allergy-focussed services and procedures. The reality of the long-term circulation of this virus in our communities requires us to evolve as a specialty. In this article, we outline current and future challenges in the management of food allergy in light of coronavirus disease 2019 (COVID-19). We focus on infant food allergy prevention, management of anaphylaxis, accurate diagnosis with oral food challenges, and active management of food allergy with oral immunotherapy. This article identifies the challenges of conflicting guidelines, shortcomings of acute management approaches, and inherent system deficiencies. We offer perspectives and strategies that can be implemented now, including an evaluation of virtual care and telemedicine for the management of food allergy. The use of a shared decision-making model results in novel approaches that can benefit our patients and our specialty for years to come. COVID-19 has forced us to re-evaluate our current way of thinking about food allergy management to better treat our patients.