FOOD allergy (FA) is becoming an increasingly prevalent threat to public health. A chronic, potentially fatal condition, the burden of FA is significant; negatively impacting not only the health and wellbeing of afflicted individuals, but also theirs and their loved ones’ quality of life (QoL). A recent systematic review and meta-analysis sponsored by the European Academy of Allergy (EAACI), the largest medical association for allergy worldwide, aims to inform clinical guidelines on the management of IgE-mediated FA with immunotherapy and biologics.
The study comprised data from 121 human studies on both adult and paediatric patients diagnosed with IgE-mediated FA, in which immunotherapy (n=111) or biologics (n=10) were prescribed therapies, independently (n=120) or in conjunction (n=1). Inclusion criteria stipulated that trials be phase II or higher, and that only studies investigating clinical outcomes be selected. Outcomes assessed were treatment efficacy and safety, as well as patient QoL. Internal validity of the trials was evaluated using the Cochrane Risk of Bias (RoB) tool for randomised control trials (RCTs) and the Cochrane ACROBAT-NRS tool for controlled clinical trials (CCTs). Results were pooled using random effect models with the Mantel-Haenzel method, and subgroup analyses were conducted where sufficient data was available.
Omalizumab was the most commonly prescribed biologic (n=8). The meta-analysis showed a short-term positive effect of omalizumab in achieving desensitization to the causative allergen (relative risk [RR] 2.17; 95% confidence interval [CI]: 1.22-3.85). Long-term effects were similarly positive but with greater uncertainty (RR 2.42; 95% CI 0.90-6.50). Adverse events data favoured the placebo group, though the rate of serious adverse events was low.
Immunotherapy, likewise, was found to have a positive effect for achieving desensitisation to causative allergens, including peanuts, cow’s milk, and eggs. In the case of peanut allergy, oral immunotherapy (OIT) produced a significant positive effect compared to avoidance or placebo, although presented a very wide confidence interval (RR=11.94, CI 95%=[1.76, 80.84). Sublingual (SLIT [RR=3.00; 95% CI: 1.04-8.66]) and epicutaneous (EPIT [RR=2.16; 95% CI: 1.56-3.00]) immunotherapies were, likewise, effective in desensitising subjects to the culprit food. Evidence was limited for subcutaneous (SCIT) immunotherapy, inhibiting any significant conclusions about its efficacy. One study (30/37) showed maintenance of desensitisation to the culprit allergen after 42 weeks, where another demonstrated maintained desensitisation in just under half (n=12) the total cohort (N=39) after 5 years.
Peanut allergies were most responsive to all treatments, with OIT being the most effective across all allergens tested. Despite positive outcomes, the authors caution against overinterpretation due to wide confidence intervals. This study, one of the few to directly compare these therapies, underscores the need for further research into the long-term effects and economic aspects of these treatments. The authors emphasise, “Determining the most cost-effective application of biologics as food allergy treatment, as monotherapy or combined with immunotherapy, remains essential.”
Reference
Santos et al. Immunotherapy and biologics in the management of IgE-mediated food allergy: Systematic review and meta-analyses of efficacy and safety. Allergy. 2024; DOI:10.1111/all.16129
