Other treatments
The effect of a 4-month treatment with omalizumab for severe asthma on the thresholds of food allergic reactions was investigated in a real-life study of 15 children with asthma and food allergies30. Among participants, there was a child with allergies to walnut, hazelnut allergies, peanut, peach, and apricot. Omalizumab administration for four months resulted in an elevation in hazelnut ED from 13,8 to 35,3mg of protein. Walnut was not evaluated.
In a similar study29 of 5 children with multiple food allergies, administration of omalizumab for at least six months resulted in tolerance for hazelnut in 3/5 children, for walnut in 1/3, for cashew in 1/2, and for almond in 2/3. One child with pistachio allergy remained allergic.
Rial et al.36 reported a case of a 30-year-old woman with severe atopic dermatitis and LTP-syndrome with multiple food allergies, including almond, pistachio, hazelnut, and walnut, and a positive OFC to pistachio. Three months after initiating treatment with dupilumab for atopic dermatitis, she reported accidental ingestion of pistachio without reaction. Tolerability was confirmed by an OFC to 50 gr pistachio.
Traditional Chinese Medicine35, and Chinese Herbal Medicine [Food Allergy Herbal Formula-2 (FAHF-2)]16, have been investigated in multi-allergic children, with inconclusive results.
Sustained Unresponsiveness
In a conference abstract, Scurlock et al.23 reported the results of 8 children with walnut and another tree nut allergy undergoing walnut-OIT for approximately three years. SU at four weeks off therapy to both walnut and another tested Tree Nut (tTN) was achieved by four subjects, to walnut only by six, and to a tTN only by five.
In the case series of Sasamoto et al.37, all children achieved two weeks SU to 450 mg after 24, 14, and 12 months on daily maintenance with 75 mg walnut.
In the study of Andorf et al.13, in the group which discontinued OIT (0 gr protein) for six weeks, SU was documented in 2/11 participants treated for cashew allergy, 8/11 for walnut, 3/6 for hazelnut, and 1/1 for almond.
Finally, in the study of Wang et al.16, three months of discontinuation of FAHF-2 retained unresponsiveness in 5/8 active-treated participants and in 3/10 placebo-treated participants.
Cross-desensitization
In the study of Scurlock et al.23, three years of walnut-OIT resulted in desensitization to both walnut and another tree nut for 7/8 children.
In the walnut-OIT study of Elizur et al.22, after walnut desensitization, all 46 children co-allergic to pecan, eight of fifteen co-allergic to hazelnut, and four of nineteen co-allergic to cashew were also fully desensitized, while six and one children with co-allergy to hazelnut and cashew respectively, were partially desensitized.
In the cashew-OIT25, 35 participants fully desensitized to cashew were also allergic to pistachio and were successfully challenged to 2500mg of pistachio protein. Ten participants were co-allergic to walnut and offered an OFC to 4000mg of walnut. Two refused the procedure. Of the eight challenged, four succeeded.
In multi-OIT studies, cross-desensitization has been assessed for walnut and pecan, and cashew and pistachio. In the omalizumab-facilitated multi-OIT study of Andorf et al.27, of the 8 participants with pecan in their OIT and 10 with walnut, seven were desensitized to both nuts.
In the subsequent trial12, 20/24 participants with cashew and pistachio allergy were desensitized to pistachio while treated with cashew, and all seventeen participants with walnut and pecan allergy were desensitized to pecan treated while treated with walnut.
In the latest study of this team13, 3/4 of pecan-allergic participants and 8/8 of pistachio-allergic participants were desensitized. Six weeks after randomization to 1000mg, 300mg, and 0 mg maintenance dose all four pecan allergic participants (1-1gr, 1-300mg, 2-0mg) and seven of eight pistachio allergic participants (3-1gr, 3-300mg, 1/2-0mg) passed the food challenge.
Quality of life assessment
In the conference abstract by Bradatan et al21 an improvement in QoL after OIT is reported without further information.
In the NutCRACKER study of walnut22, age-appropriate FAQLQ from 52 patients were assessed. Children desensitized to all tested nuts reported significant improvement in the total FAQLQ and the sub-scores of emotional impact, food anxiety, and social and dietary limitation. In children remaining allergic to at least one nut, statistically, but not clinically, significant improvement was noted only for the social and dietary limitation scores.
Otani et al.17 compared the effect of multi-OIT with and without omalizumab on Food Allergy Quality of Life-Parental Burden (FAQL-PB) Questionnaire against food avoidance. FAQL improved in active groups. In controls, FAQL worsened at six months and returned to baseline levels at 18 months of follow-up.
Arasi et al.18 used the FAQL-PB questionnaire to assess the effect of peanut or multi-OIT on food allergy-specific health-related quality of life (HRQL) over a 24 month-follow-up in caregivers of children. Scores improved significantly; 42% of caregivers reported improvement at six months, 71% at 12 months, 76% at 18 months, and 92% at 24 months. Changes in the HRQL between baseline and 24 months were associated with older age, the absence of asthma, the absence of dose-related respiratory allergic reactions, and the greater number of foods in OIT.
Fiocchi et al.30, used the ”Pediatric Quality of Life Inventory” (PedsQL) 4.0 questionnaire in 15 children. The total score, the physical, emotional, social, and cognitive functioning, were improved in children and parents after four months on omalizumab.
The Parent Form of the ”Food Allergy Quality of Life Questionnaire” (FAQLQ-PF) was used by Crespo et al.29. After two years on omalizumab, parents perceived an improvement in the health status of their children. The stress associated with the allergy was reduced, and the limitations of the child’s activities in their daily life decreased.
In the study of Lisann et al.35, the ”Food hypersensitivity family impact” (FLIP) questionnaire was improved in the three participating children after six months of Traditional Chinese Medicine.
Finally, Sabouraud et al.33 used a non-validated Likert questionnaire (scale 1-7), addressed to 42 children >8 y.o. and their caregivers, to assess children’s acceptance of OIT. The questionnaire was completed at a median of 47,5 months after the initial consultation. The median score for children’s satisfaction was 5. Children considered OIT effective (6) and reported that would recommend it to another child with allergy (7). On the other hand, children did not enjoy eating hazelnut every day (3), and OIT was considered a strain (5) and medication (4).