Food Allergy Is Another Looming Epidemic

Food Allergy Is Another Looming Epidemic

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Food allergy, defined as an inappropriate immune response after exposure to foods that cause no problems in most individuals, is a widespread and growing challenge in Western countries and a global concern.1-3 Experts partially attribute the surge in cases to genetics but have identified epigenetic (heritable changes in gene function without a change in DNA sequence) and environmental factors as well. Traditional management has been simple in theory and difficult in practice: avoidance of the offending food and use of rescue medication.

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Individuals can develop food allergies at any age, but they are most common in children. Eggs, fish, milk, peanuts, sesame, shellfish, soy, tree nuts, and wheat are most often implicated.4 Food allergies present in numerous ways and in varying severities (Table 1). Most, but not all, children outgrow or become tolerant of egg, milk, soy, and wheat allergies, but fish, peanut, shellfish, and tree nut allergies can be persistent. Children with non-immunoglobulin E (IgE)–mediated food allergies often outgrow them early in life,5 but only approximately 20% of children outgrow peanut allergy by the time they start school.4 Any food can lead to anaphylaxis in allergic individuals, but peanuts, tree nuts, fish, and shellfish are most often associated with severe anaphylaxis.6

MECHANISMS REVEAL POTENTIAL TREATMENT APPROACHES

Information about the mechanisms of food allergies and new prevention strategies is growing, as are available treatments. Better understanding of immune tolerance and induction of regulatory T (Treg) cells, T-helper type 2 (Th2) cell–driven responses, and subsequent proinflammatory cytokine production has been key.

The FDA has approved an oral immunotherapy, peanut (Arachis hypogaea) allergen powder-dnfp (PTAH; Palforzia), to mitigate allergic reactions, including anaphylaxis, pursuant to accidental exposure to peanuts.7 PTAH is approved for children aged 4 to 17 years with confirmed peanut allergy, and patients who use PTAH must continue to avoid peanuts. Its mechanism of action has not been established.

Administration consists of 3 phases: initial dose escalation, up-dosing, and maintenance.7 Real-world data indicate most patients have successfully navigated the 3 phases, and adherence tends to be excellent.8 Available through a Risk Evaluation and Management Strategy program, the most common adverse reactions associated with PTAH are abdominal pain, vomiting, nausea, and various allergic symptoms including anaphylaxis.8

Research is underway to determine whether monoclonal antibodies targeting interleukin (IL)-4, IL-5, and IL-13 that disrupt Th2 cell–related pathways can help. Omalizumab (Xolair; Genentech and Novartis), approved in several atopic conditions, is considered investigational in food allergy. Ligelizumab (Novartis) and dupilumab (Dupixent; Sanofi and Regeneron) are also being studied in food allergy.9

MANAGEMENT

Currently, food allergy is considered incurable. It is also a unique response, and pharmacists should note that food allergy differs from other food-related concerns (Table 2).

Until recently, pediatricians advised new parents to withhold potentially allergenic foods from infants until after their first birthday or even later. Recent research changes that advice: Introducing infants to potential allergens at an early age may reduce the risk of developing allergies to those foods.10,11 In patients who continue to have food allergies, strict avoidance of the offending food is essential. Avoidance can be difficult, as many foods may contain or are cross-contaminated with allergens.

Patients can use antihistamines to relieve mild symptoms like itching or hives, but antihistamines are not appropriate to treat severe allergic reactions. Patients who have food allergies, especially if they have had or are at risk for anaphylaxis, should carry epinephrine autoinjectors. Patients with the most severe reactions may need corticosteroids.

CONCLUSION

Although food allergy is increasing in incidence, scientific developments are finding new ways to mitigate its effects. The next few years should produce better interventions. For now, pharmacists should counsel patients carefully and ensure they have rescue measures available in the unfortunate event of anaphylaxis.

About the Author

Jeannette Y. Wick, RPH, MBA, FASCP, is the director of the Office of Pharmacy Professional Development at the University of Connecticut, in Storrs.

References

  1. Cianferoni A, Spergel JM. Food allergy: review, classification and diagnosis. Allergol Int. 2009;58(4):457-466. doi:10.2332/allergolint.09-RAI-0138
  2. Sampath V, Abrams EM, Adlou B, et al. Food allergy across the globe. J Allergy Clin Immunol. 2021;148(6):1347-1364. doi:10.1016/j.jaci.2021.10.018
  3. Seth D, Poowutikul P, Pansare M, Kamat D. Food allergy: a review. Pediatr Ann. 2020;49(1):e50-e58. doi:10.3928/19382359-20191206-01
  4. Wood RA. The natural history of food allergy. Pediatrics. 2003;111(suppl3):1631-1637.
  5. Mehr S, Kakakios A, Frith K, Kemp AS. Food protein-induced enterocolitis syndrome: 16-year experience. Pediatrics. 2009;123(3):e459-464. doi:10.1542/peds.2008-2029
  6. Bock SA, Muñoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007;119(4):1016-1018. doi:10.1016/j.jaci.2006.12.622
  7. Palforzia. Prescribing information. Aimmune Therapeutics; 2020. Accessed August 31, 2023. https://www.palforzia.com/sites/default/files/2023-03/stn125696-pi-clean.pdf
  8. Portnoy J, Shroba J, Tilles S, et al. Real-world experience of pediatric patients treated with peanut (Arachis hypogaea) allergen powder-dnfp. Ann Allergy Asthma Immunol. 2023;130(5):649-656.e4. doi:10.1016/j.anai.2023.01.027
  9. Nsouli TM. New insights in the optimal diagnosis and management of food allergy. Allergy Asthma Proc. 2023;44(5):306-314. doi:10.2500/aap.2023.44.230046
  10. Du Toit G, Roberts G, Sayre PH, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med. 2015;372(9):803-813.doi:10.1056/NEJMoa1414850
  11. Greer FR, Sicherer SH, Burks AW; Committee on Nutrition; Section on Allergy and Immunology. The effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, hydrolyzed formulas, and timing of introduction of allergenic complementary foods. Pediatrics. 2019;143(4):e20190281. doi:10.1542/peds.2019-0281

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