Diagnosis and prevention of food-dependent exercise-induced anaphylaxis

ABSTRACT

Introduction: Food-dependent, exercise-induced anaphylaxis (FDEIA) is a rare type of anaphylaxis with a growing incidence. Although the precise mechanism by which the patient reacts only in a combination of a culprit food and cofactors are not currently understood, many advances in diagnosis and management have been made since their first description.

Areas covered: A literature search in PubMed was performed to review the diagnosis and management of FDEIA. Clinicians should have a high level of suspicion for identification of the culprit foods and the cofactors involved. Component-resolved diagnosis and more accurate provocation tests have revolutionized the diagnosis accuracy. Management is not easy and involves educating the patient to evict the combination of exposure to the culprit foods and the cofactors that elicit anaphylaxis, and how to act and treat if a reaction occurs.

Expert opinion: FDEIA is currently misdiagnosed and the authors believe that there are many FDEIA patients labelled as idiopathic anaphylaxis with unnecessary evictions and with a poor quality of life because of the fear of an imminent reaction. Due to recent advances in diagnostic tools and the use of monoclonal antibodies for prophylaxis in persistent cases, FDEIA can have a better prognosis improving the quality of life of the patients and their families.

KEYWORDS:

• Anaphylaxis
• augmenting factors
• cofactors
• exercise-induced anaphylaxis
• food allergy
• food-dependent exercise-induced anaphylaxis
• food-exercise provocation test

Article highlights

• FDEIA is frequently misdiagnosed and a high level of suspicion is necessary.

• The precise prevalence and physiopathology of FDEIA remain unclear.

• As a special type of IgE-mediated food allergy, any food can trigger the condition, and a detailed clinical history is of importance.

• Exercise is not the only cofactor that can elicit a reaction; other cofactors like NSAIDs and alcohol and combinations of two or more cofactors can prompt a reaction.

• Component-resolved diagnosis revolutionized the diagnosis of food allergy and have a crucial role in FDEIA patients.

• FDEIA diagnosis is based on a combination of provocation tests that include a food challenge, a cofactor challenge, followed by a combined food–cofactor challenge or a challenge with high amounts of the culprit food.

• Provocation tests mimicking an environment closer to real life using standardized protocols, and advances in molecular diagnosis will improve diagnosis.

• Management is based on avoidance of the culprit food and the cofactors, especially not combining them, be aware of signs and symptoms and how to act in case of an anaphylactic reaction. Clinicians should prescribe an epinephrine auto-injector to all FDEIA patients and teach them how to use it

• Monoclonal antibodies and food immunotherapy are promising tools for prophylaxis for selected patients: those with more persistent reactions or the ones that food and cofactors avoidance are difficult to accomplish.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.