Severe Anaphylactic Reactions to Home Doses of Oral Immunotherapy for Food Allergy

Liat Nachshon; Naama Schwartz; Michael B Levy; Michael Goldberg; Naama Epstein-Rigbi; Yitzhak Katz; Arnon Elizur

doi:10.1016/j.jaip.2023.03.005

Severe Anaphylactic Reactions to Home Doses of Oral Immunotherapy for Food Allergy

J Allergy Clin Immunol Pract. 2023 Aug;11(8):2524-2533.e3. doi: 10.1016/j.jaip.2023.03.005. Epub 2023 Mar 15.

Authors

Liat Nachshon¹, Naama Schwartz², Michael B Levy³, Michael Goldberg⁴, Naama Epstein-Rigbi⁴, Yitzhak Katz⁴, Arnon Elizur⁴

Affiliations

¹ Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel. Electronic address: Liatna2@gmail.com.
² School of Public Health, University of Haifa, Haifa, Israel.
³ Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel.
⁴ Institute of Allergy, Immunology, and Pediatric Pulmonology, Yitzhak Shamir Medical Center, Beer Yaakov, Israel; Department of Pediatrics, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

PMID: 36925102
DOI: 10.1016/j.jaip.2023.03.005

Abstract

Background: Severe anaphylactic reactions to home doses may occur during food allergy oral immunotherapy (OIT).

Objective: To study the rate and risk factors for such reactions.

Methods: We studied all patients aged greater than 3.5 years who completed OIT in a single center between April 2010 and January 2020. All home epinephrine-treated reactions (HETRs) were identified. High-grade HETRs (HG-HETRs) were defined as HETRs involving respiratory (SpO₂ of 94% or less), cardiovascular (low blood pressure), or central nervous system impairment (loss of consciousness). We investigated the rate and risk factors for HG-HETRs.

Results: A total of 1,637 OIT treatments were studied: milk (880), peanut (346), tree nuts (221), sesame (115), and egg (75). Of 390 identified HETRs, 30 HG-HETRs occurred during 27 treatments (1.65% of all treatments). Nearly all (26 of 30) were during milk OIT in patients with house dust mite (HDM) sensitization and asthma (26 of 30 each). Of the 30 patients with HG-HETRs, 21 recovered with one or two epinephrine treatments, but nine (0.55% of all treatments) did not respond to a second dose of epinephrine and were deemed to have refractory anaphylaxis. Three patients required intensive care unit admission and three received epinephrine drip, but none required ventilatory support. Risk factors for HG-HETRs included milk OIT (P = .031), asthma (P = .02) and HDM sensitization (P = .02). No specific triggers for HG-HETR were identified. Of patients with HG-HETRs, 25.9% were fully desensitized, including the four non-milk treated patients; 22.2% were partially desensitized; and 51.9% failed.

Conclusions: High-grade HETRs are uncommon, particularly refractory anaphylactic reactions to home OIT doses. Although milk OIT, asthma, and HDM sensitization are the main risk factors for such reactions, identification of patients who are at risk is challenging.

Keywords: Adverse reactions; Anaphylaxis; Epinephrine; Oral immunotherapy; Vital sign.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Administration, Oral
Aged
Allergens / adverse effects
Anaphylaxis* / drug therapy
Animals
Dermatophagoides pteronyssinus
Desensitization, Immunologic / adverse effects
Epinephrine / therapeutic use
Food Hypersensitivity* / complications
Food Hypersensitivity* / epidemiology
Food Hypersensitivity* / therapy
Humans
Risk Factors

Substances

Epinephrine
Allergens