Infectious Disease

Simultaneous oral immunotherapies for multiple foods deemed safe, feasible


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Key takeaways:

  • 10.9% of initial dose escalations resulted in failures.
  • 8.6% of patients required epinephrine during dosing at home.
  • No patients discontinued treatment once reaching maintenance.

Single-food oral immunotherapy and simultaneous OITs for multiple foods both were safe and feasible via established protocols, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.

Gastrointestinal symptoms were the most common reactions that caused patients to halt therapy, Kim Nguyen, MD, fellow, division of allergy and immunology, Children’s Hospital of Philadelphia, and colleagues wrote.

Data were derived from Nguyen K, et al. J Allergy Clinic Immunol Pract. 2023;doi:10.1016/j.jaip.2023.03.002.

The retrospective review involved 151 children (66.9% boys; 75.5% white) aged 1.1 to 17.4 years (mean age, 8.6 years) who had an initial dose escalation (IDE) or standard oral food challenge for one or more foods.

However, 12 failed the IDE and did not proceed to updosing. Eleven patients who mostly were receiving OIT for peanut alone discontinued treatment due to symptoms after updosing began. Nine of these patients experienced gastrointestinal symptoms such as abdominal pain and vomiting.

The 128 remaining patients included 78 actively receiving single-food OIT, with 53 (67.9%) reaching maintenance dosing and 25 (32.1%) who were still updosing when the data was analyzed. The most common allergens in this group were peanut, egg and milk.

The treatment group also included 50 patients actively receiving multi-food OIT, including 18% treated for two foods, 12% treated for three foods, 8% treated for four foods and 1% treated for five foods. Additionally, 43 (86%) reached maintenance dosing for at least one of their allergens and 34 (68%) reached maintenance for all of their allergens.

During the study, there were 229 IDEs with 25 failures (10.9%), defined as moderate to severe reactions preventing the patient from proceeding to OIT for the failed food, among 24 patients. Twenty (8.7%) of these reactions required epinephrine, and two of these reactions (0.9%) required more than one dose of epinephrine.

The IDE failures also included 10 escalations involving patients on single-food OIT and 15 escalations involving patients who were on multi-food OIT and/or who had at least one previous IDE to another food. The 24 patients who failed an IDE included 12 who discontinued OIT and did not proceed to updosing for any food.

Among the 139 patients who proceeded to updosing, 30 (21.6%) developed a reaction during updosing in the clinic, although the researchers said most of them only required minimal or no clinical intervention. The three patients (2.9%) who had anaphylaxis in the clinic during updosing required a dose of epinephrine with or without antihistamines.

There was one patient who required epinephrine for anaphylaxis at home after updosing for cashew and peanut in the clinic, but this patient did not go to the ER due to parental preference during the COVID-19 pandemic. This patient discontinued OIT for cashew but continued with treatment for peanut.

Home dosing led to epinephrine in 8.6% of patients after administration of the incorrect dose, physical activity within 2.5 hours of dosing, hot baths an hour before dosing, or dosing during an illness.

While 60% of the 128 patients in active OIT did not receive any premedication before their daily doses, 40% were receiving at least one premedication, including 18% of all active OIT patients taking an H1 antagonist only and 15.6% taking both an H1 and H2 antagonist before their daily doses. Two patients used a proton pump inhibitor before dosing.

The 23 patients who failed an IDE or discontinued OIT entirely included 20 who failed a single IDE or who were being treated with single-food OIT.

Overall, there was a 10.9% IDE failure rate, and 20 of the 25 IDE failures or 8.7% of the total IDEs required epinephrine. Also, 7.9% of patients stopped OIT after updosing had begun, and none of the patients stopped OIT once they reached maintenance dosing.

Cashews were associated with the greatest number of failed IDEs, with one patient experiencing anaphylaxis and requiring epinephrine and an ED visit. Another patient required admission to the pediatric ICU during a sesame IDE.

Based on these findings, the researchers called desensitization to one food or multiple foods simultaneously through established OIT protocols safe and feasible, with further studies needed to assess their efficacy, sustained unresponsiveness and predictors of success.


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Na'ama Epstein Rigbi, MD)

Na’ama Epstein Rigbi, MD

I read this paper with great interest. These findings are significant mostly because a substantial number of patients suffer from multiple food allergies. While OIT in general can have a positive impact on their life, multiple food OIT can bring quicker relief. Multiple food OIT is also an efficient way to treat larger masses of patients and shorten their waiting time.

My only reservations concern the amount of protein given for the maintenance dose. While the approach in this work is common, my colleagues and I believe that larger maintenance doses are required for a profound improvement in the quality of life, both personal and social.

However, more research might prove me wrong. If these patients, after consuming a low maintenance dose for several years, pass challenges for much higher doses, then this practicality might be more feasible and easier to maintain.

Na’ama Epstein Rigbi, MD

Institute of Allergy, Immunology and Pediatric Pulmonology, Shamir Medical Center

Disclosures: Epstein Rigbi reports no relevant financial disclosures.


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