Treatment of food allergy: what is new? 2018 WSAAI update

This is a Twitter summary from the 2018 WSAAI meeting. This summary was compiled from the tweets posted by @MatthewBowdish, an allergist/immunologist, who attended the 2018 Western Society of Allergy, Asthma and Immunology (WSAAI) meeting. The tweets were labeled #WSAAI. The text was edited and modified by me.

Robert A Wood discussed "Current and Future Prospects for the Treatment of Food Allergy".

The risks of subcutaneous immunotherapy with food allergens appear to outweigh the benefits. Alternatives include allergen modification, DNA vaccines, Adjunctive treatments (adjuvants, meds to decrease adv rxns) and different routes (OIT, SLIT, EPIT).

Most food allergen immunotherapy studies suggest that these will be lifelong treatments.



Food allergy - Only 3 ways to treat allergies (click to enlarge the image).

Dr Wood reviewed results of CoFAR egg OIT Trial (NEJM 2012): https://twitter.com/MatthewBowdish/status/956715210093441024

The follow-up to the CoFAR Egg OIT study (JACI 2016) showed that in the 22 subjects still dosing in years 3 and 4, 54.5% still reported reactions with dosing.

When compared with subjects not achieving sustained unresponsiveness (SU), subjects achieving SU had higher IgG4 values. So, IgG4 for foods may be a decent biomarker.

SLIT vs. OIT

Comparing milk SLIT and OIT (Keet JACI 2012), at 15 months, 10% were desensitized with SLIT, 60% with OIT. While we temporarily killed SLIT for awhile with this study, we will definitely see more SLIT research in the future. Milk SLIT vs OIT - Adverse Reactions: https://twitter.com/MatthewBowdish/status/956718123008253952

Summary of OIT Efficacy (more than 30 studies): https://twitter.com/MatthewBowdish/status/956718359868928000

Adverse reactions with OIT:

-types & frequency of rxns appear similar for different foods-PN, milk, wheat, egg
-overall reaction rates very high but most are mild
-moderate rxns occur in less than 10% of doses, severe reactions in less than 1% of doses
-but significant reactions are very common due to having to take so many doses

Significant reactions with OIT are at least twice as common, and more likely 10 to 20 times more common, than would be expected with strict avoidance.

Chronic GI symptoms are common, and are the most common reason to discontinue therapy (10-25%); the true incidence of EoE is not clear; are the benefits worth the risk?

If you did EGD on everyone who received OIT, there would probably be a significant number who had eosinophils just not with clinical symptoms - these are highly atopic kids getting foods they're allergic to. Even those who only have transient GI sxs don't always get EGD.

JACI article looked at using omalizumab for cow's milk OIT - Conclusions: safety was improved with regard to acute rxns but not GI symptoms, with or w/o Xolair, most subjects could be desensitized to high dose (10g) of milk protein but half had increased reactivity after 8 week period of avoidance.

Milk OIT Follow-up: Conclusions: https://twitter.com/MatthewBowdish/status/956721644759760896

Patch therapy with Peanut - EPIT - Lots of mild to moderate patch reactions, making long-term use difficult (therapy will be needed for years).

CoFAR EPIT Conclusions: https://twitter.com/MatthewBowdish/status/956723522247704578

Further study is needed to:

-minimize adverse reactions
-improve efficacy, ideally with induction of long-term protection
-identify biomarkers, especially for those at risk for adverse reactions & most at risk to lose protection
-long-term studies showing good outweighs potential harms

Additional IT studies currently underway: https://twitter.com/MatthewBowdish/status/956724695943884800

Novel therapies underway: https://twitter.com/MatthewBowdish/status/956725028162174977



Allergic Rhinitis vs. Food Allergy - Efficacy of different treatment approaches (click to enlarge the image).