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).