Food desensitization: current knowledge and future directions
Moshe Ben-Shoshana,b, Ann Clarkeb,c and Bruce Mazera
- Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Center, Montreal, Quebec, Canada
- Division of Clinical Epidemiology, Department of Medicine, McGill University Health Center
- Division of Allergy and Clinical Immunology, Department of Medicine, McGill University Health Center
Foods are reported to be primary causes for anaphylaxis(1) and a recent study in Montreal suggests that almost 85% of anaphylaxis cases in children are triggered by food with peanut and/or tree-nut being the major culprit(2). At present, the only treatment for food allergy is strict avoidance of the food, while the principal treatment for an allergic reaction is prompt administration of intramuscular epinephrine (found in Epipen® and Allerject™) (3).
While peanut and tree nut allergy account for the majority of anaphylaxis cases, cow’s milk allergy (CMA) is the most common food allergy in children. CMA is associated with severe and frequent allergic reactions, anaphylaxis, and potential nutritional deficiencies. Due to the common use of cow’s milk in Western diets, it is almost impossible to avoid (4) and hence, new treatment strategies apart from avoidance have been sought for individuals presenting with food allergy in general and CMA in particular.
Immunotherapy has been utilized for inhalant allergies, such as to grass tree or ragweed hay fever, for over a century. Allergen Immunotherapy is based on injection of increasing amounts of a specific allergen over a prolonged period. However, attempts at food based injected-immunotherapy were associated with severe adverse effects (5). Instead of injected immunotherapy, recent studies have attempted oral administration of small, increasing amounts of the food over a period of weeks to allow patients to be able to ingest the food.
Milk immunotherapy is mainly indicated for food allergy which is present after the usual age of recovery, which in most cases is age 5. There are currently no guidelines describing the perfect candidate for desensitization or the safest and most effective dosing schedule(6). Several initiatives exploring the effective immunotherapy for food allergies have been advanced. The ultimate goal of food allergy immunotherapy is cure, resulting children having no symptoms after ingestion of the food even after prolonged periods of avoidance. However, it is not clear if the current food immunotherapy projects can achieve tolerance, or would have to remain on dosing daily dose to be safe(7).
In our recent publication on milk immunotherapy, 66 patients (62%) in a group treated with immunotherapy were able to tolerate a full serving of milk (about 200 mL) compared to seven (8%) of the untreated control group. In addition, 27 (25%) in the treated group could drink a smaller serving of milk (10 to 184 mL) while none could in the control group. None of the studies on milk immunotherapy assessed the patients following a period off treatment. Side effects were common, although most were local and mild(8). Significantly increased thresholds to food-induced allergic reactions after oral immunotherapy were described also for other foods including egg and peanut (9) (10) (11).
In 2013 the, Division of Allergy and Clinical Immunology in The Montreal Children’s Hospital has initiated a randomized controlled trial to assess oral desensitization to cow’s milk as a treatment for CMA. Children with a history of CMA will undergo a blinded milk challenge at study entry to establish the presence of CMA and assess their reaction threshold. Children with an established CMA will be randomized to receive either oral immunotherapy or to serve as control group for the study period. This study will evaluate the clinical and immunological parameters that will help predict the ideal protocol and candidates to apply this strategy to the large population of children and adolescents with CMA.
- Ben Shoshan M, Clarke AE. Anaphylaxis: past, present and future. Allergy 2010.
- Ben-Shoshan M, La vieille S, Eisman H, Alizadehfar R, Mill C, Perkins E et al. Anaphylaxis in Children Treated At the Montreal Children's Hospital: Rate, Clinical Characteristics, Triggers and Management. J Allergy Clin.Immunol. 2013. Ref Type: Abstract
- Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of anaphylaxis. J Allergy Clin Immunol 1998; 101(1 Pt 1):33-7.
- Fiocchi A, Schunemann HJ, Brozek J, Restani P, Beyer K, Troncone R et al. Diagnosis and Rationale for Action Against Cow's Milk Allergy (DRACMA): a summary report. J Allergy Clin Immunol 2010; 126(6):1119-28.
- Oppenheimer JJ, Nelson HS, Bock SA, Christensen F, Leung DY. Treatment of peanut allergy with rush immunotherapy. J Allergy Clin Immunol 1992; 90(2):256-62.
- Plaut M, Sawyer RT, Fenton MJ. Summary of the 2008 National Institute of Allergy and Infectious Diseases-US Food and Drug Administration Workshop on Food Allergy Clinical Trial Design. J Allergy Clin Immunol 2009; 124(4):671-8.
- Rachid R, Umetsu DT. Immunological mechanisms for desensitization and tolerance in food allergy. Semin Immunopathol 2012; 34(5):689-702.
- Yeung JP, Kloda LA, McDevitt J, Ben-Shoshan M, Alizadehfar R. Oral immunotherapy for milk allergy. Cochrane Database Syst Rev 2012; 11:CD009542.
- Buchanan AD, Green TD, Jones SM, Scurlock AM, Christie L, Althage KA et al. Egg oral immunotherapy in nonanaphylactic children with egg allergy. J Allergy Clin Immunol 2007; 119(1):199-205.
- Jones SM, Pons L, Roberts JL, Scurlock AM, Perry TT, Kulis M et al. Clinical efficacy and immune regulation with peanut oral immunotherapy. J Allergy Clin Immunol 2009; 124(2):292-300, 300.
- Burks AW, Jones SM, Wood RA, Fleischer DM, Sicherer SH, Lindblad RW et al. Oral immunotherapy for treatment of egg allergy in children. N Engl J Med 2012; 367(3):233-43.