Pharmacologic options for the treatment and management of food allergy

Abstract

Food allergy affects approximately 5% of adults and 8% of children in developed countries, and there is currently no cure. Current pharmacologic management is limited to using intramuscular epinephrine or oral antihistamines in response to food allergen exposure. Recent trials have examined the efficacy and safety of subcutaneous, oral, sublingual, and epicutaneous immunotherapy, with varying levels of efficacy and safety demonstrated. Bacterial adjuvants, use of anti-IgE monoclonal antibodies, and Chinese herbal formulations represent exciting potential for development of future pharmacotherapeutic agents. Ultimately, immunotherapy may be a viable option for patients with food allergy, although efficacy and safety are likely to be less than ideal.

Keywords:

• adjuvant
• allergy
• anaphylaxis
• egg
• epicutaneous
• food
• immunotherapy
• milk
• multifood
• omalizumab
• oral
• peanut
• probiotic
• sublingual

Financial & competing interests disclosure

W Burks has consulting agreements with the following commercial entities: Allertein, Dynavax Technologies Corp, GLG Research, Mastcell Pharmaceuticals, Inc., Perrigo Company, Regeneron Pharmaceuticals, Inc., Perosphere, Inc., ActogeniX, Genetech, Valeant Pharmaceuticals and Sanofi US Services. He serves on the boards of FARE, World Allergy Organization and Murdoch Children’s Research Institute, and has research sponsored by Hycor Biomedical and Allergen Research Corporation. W Burks holds a faculty appointment at The University of North Carolina at Chapel Hill. The authors have no other 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 apart from those disclosed.

Key issues

• Oral immunotherapy has shown high rates of efficacy in desensitization, but is limited by adverse events including anaphylaxis and eosinophilic esophagitis.

• Sublingual immunotherapy has shown inferior efficacy in desensitization, but seems to be safe and well tolerated.

• Epicutaneous immunotherapy has shown some efficacy in early studies and seems to be well tolerated, although further study is needed.

• Anti-IgE therapy with omalizumab has been used as adjunctive agent in desensitization and may be useful in patients with multi-food allergy or severe food allergy.

• Probiotic adjuvants used with oral immunotherapy have shown high rates of desensitization in a small study.

• Chinese herbals have shown great potential mechanistically, and human trials are underway.

• The future paradigm in food allergy may shift goals: from desensitization and incorporation into diet to achieving a minimal level of tolerance.