Louisville Medicine Volume 66, Issue 2 - Page 29

FEATURE cient for diagnosis. However, in the presence of a strong suggestive history of food allergy, these can confirm the diagnosis without further need for an oral food challenge. Despite recent advances in diagnostic testing and food challenges, there is still no correlation with severity of food allergy reactions. 5 It is not uncommon for patients to seek other non-validated types of testing to investigate possible food allergy. Unconventional testing for adverse reactions to foods include tests such as flow cytometry, measurement of serum IgG or IgG4 antibodies directed against foods, intradermal provocation-neutralization with food allergens, hair analysis, electrodermal testing and applied kinesiology. These tests lack scientific evidence supporting their validity, and there is potential harm to patients from using such techniques for ruling in or out food allergy. 7 Currently, there is no FDA approved therapy for food allergy. However, in the past decade, several routes of immunotherapy have been evaluated for food allergy. These include oral immunother- apy (OIT), sublingual immunotherapy (SLIT), and epicutaneous immunotherapy (EPIT). All approaches to date are successful to variable degrees in achieving desensitization, defined as increased threshold for reaction to the food allergen, with regular exposure to the allergen. None of these experimental therapies have been shown to lead to permanent tolerance or cure, defined as the absence of symptoms after ingestion of the food allergen ad libidum (at one’s pleasure) after prolonged periods of avoidance. Safety is a major concern, as anaphylaxis has been known to occur while on therapy. Studies are still ongoing. 9 References Standard-of-care for food allergy consists of food avoidance and keeping rescue medications such as epinephrine readily availa ble for emergency use. Physicians should counsel patients and patient families on allergen avoidance for a variety of settings including home, school and travel. At home, care is needed during food preparation to avoid cross-contact of allergen with safe foods. In- formation about obtaining safe packaged foods by careful reading of food labels should be discussed. 5 1. Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pon- gracic, et al. The prevalence, severity, and distribution of child- hood food allergy in the United States. Pediatrics 2011;128:e9-17. 2. Sicherer SH, Sampson HA. Food allergy: epidemiology, patho- genesis, diagnosis, cand treatment. J Allergy Clin Immunol 2014;133:291-307. 3. Sicherer SH, Munoz-Furlong A, Godbold JH, Sampson HA. US prevalence of self-reported peanut, tree nut, and sesame allergy: 11-year follow-up. J Allergy Clin Immunol 2010;125:1322-6. While food allergen avoidance is the key to prevent a food re- action, patients should be educated to recognize the symptoms of food-induced anaphylaxis. Emphasis should be placed on prompt awareness of anaphylaxis and swift intervention. Epinephrine is the first-line and only approved therapy for the treatment of anaphylaxis. Epinephrine autoinjectors (EAI) are the recommended method for self-administration by patients. Currently, EAIs are available in three different devices in three different doses. Dosing decisions should be made by patient weight. Patients greater than or equal to 30 kg (66 lbs) should be prescribed a 0.3 mg EAI, patients 15 to 30 kg (33 to 66 lbs) 0.15 mg EAI, and patients 7.5 to 15 kg (16.5 to 33 lbs) a 0.1 mg EAI. There is NO contraindication for the use of epinephrine in treating anaphylaxis, even in adult patients with cardiac histories. The delay of epinephrine administration is known to increase the risk for severe anaphylaxis and death. 4. Dyer AA, Lau CH, Smith TL, Smith BM, Gupta RS. Pediatric emergency department visits and hospitalizations due to food-in- duced anaphylaxis in Illinois. Ann Allergy Asthma Immunol 2015;115:56-62. 5. Boyce, J.A., Assa’ad, A., Burks, A.W., Jones, S.M., Sampson, H.A., Wood, R.A. et al. Guidelines for the diagnosis and management of food allergy in the United States: report of the NIAID-sponsored expert panel. (IV)J Allergy Clin Immunol. 2010; 126: S1–S58. 6. Gupta, R., Holdford, D., Bilaver, L., Dyer, A., Holl, J.L., and Meltzer, D. The economic impact of childhood food allergy in the United States. JAMA Pediatr. 2013; 167: 1026–1031 7. Kelso JM. Unproven diagnostic tests for adverse reactions to foods. J Allergy Clin Immunol Pract 2018;6:362-5. 8. Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, et al. Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 2015;372:803-13. Due to the alarming increased incidence of food allergy, studies have investigated ways to prevent food allergies. Over the past several decades, there has been an emphasis on delayed introduction of al- lergic foods. Despite delayed introduction, data suggests an increase in the rate of clinical food allergy while the rate of sensitization has remained largely unchanged. In the Learning Early About Peanut (LEAP) study, where infants were randomized to early or delayed peanut introduction, rates of IgE sensitization were unchanged between the groups, despite the nearly 90 percent reduction in true peanut allergy with early introduction. New guidelines recommend- ing the introduction of allergenic foods earlier will hopefully reduce the rate of clinically significant food allergy and may reverse trends seen over the past few decades. 8 9. Rachid R, Keet C. Current status and unanswered questions for food allergy treatments. J Allergy Clin Immunol Pract 2018;6:377- 82. Disclosures: Dr. Wes Sublett is the Director of Clinical Research at Family Allergy & Asthma. No funding was received for the writing or publication of this article. J W Sublett has the following financial relationships which may be related to this article: Aimmune Therapeutics, DBV Technologies, Kaleo Pharmaceuticals, Mylan, Novartis, Sanofi. JULY 2018 27