Multi-OIT
Begin et al.20 first investigated the safety of the approach in 25 children in comparison to peanut-only-OIT. After an initial escalation day (IED), the dose was increased every two weeks until maintenance (2gr protein per food). In the multi-OIT group, 13 participants included cashew in their regimen, 14 walnut, 7 pecan, 3 hazelnut, and 5 almond. There was no statistical difference in dose progression comparing the number or the combinations of foods in the OIT mix. All participants reached a 10-fold increase in their ED. Adverse reactions did not differ between peanut-only and multi-OIT groups. Most reactions were mild, regarding mainly abdominal pain. Epinephrine was required during home dosing for two participants in each group.
In the follow-up study by Andorf et al.28, 46 participants, on a maintenance dose of 2gr per food, were followed up for up to 72 months to evaluate the feasibility of SU on lowering the dose from 2gr to 300mg and/or altering the frequency of dosing. In the ”high” maintenance group, cashew was included in 13 participants; walnut in 3, pecan in 3, none had hazelnut, and 2 had almond. In the ”low” maintenance group none had cashew, 10 had walnut, 5 had pecan, 3 had hazelnut, and 3 almond. Of the 25 participants with more than one food in their OIT, 10 were on a low, and 10 were on a high maintenance dose for all foods at the end of the follow-up. At the end of the study, the proportion of participants per allergen on the low dose was 66,6% for walnut, 62,5% for pecan, 100% for hazelnut, 60% for almond, and 46,2% for cashew. Each participant could tolerate ≥ 2g protein in an OFC of his respective food allergens, independent of the high or the low dose. During the study, 1207 reactions were observed, with a median of 25 reactions per participant. The reactions were mainly mild, 129 were moderate, and 5 were severe, with nasal congestion and skin symptoms only. Neither fatal nor serious adverse events nor epinephrine administration were described. The frequency of allergic adverse events decreased over time. Safety did not differ between groups.
Eapen et al.31 reported their two years’ experience with multi-food OIT in 45 children. OIT protocol and maintenance dose were individualized. The multi-OIT regimen contained cashew/pistachio in 34 children, walnut/pecan in 25, hazelnut in 13, and almond in 8. At 18 months, 35 children were on daily maintenance, four were on three times per week after 6, 8, 10, and 24 months on daily maintenance, and six had discontinued. Allergic reactions occurred in 22 children during the up-dosing or in the first three months of maintenance. Most reactions were of grade 1, according to Sampson’s grading, 9% were grade 2, and none was grade 3. The reactions resolved with no medication in 29 children and with antihistamines in 22. One child needed albuterol, and three epinephrine administrations were reported, all at home. Four children visited the Emergency Department for food allergy reactions, compared to 7 out of 44 children on a waiting list to start OIT during a similar period of 18 months.