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Risk factors for home epinephrine-treated reactions during oral immunotherapy (OIT)

Published online: August 1, 2020

Anaphylactic reactions occurring during the home treatment phase of OIT for food allergy are a major drawback. Reactions treated with epinephrine are, in particular, reflective of patients' perception of severe reactions.

In a study published in The Journal of Allergy and Clinical Immunology: In Practice, Nachshon et al studied risk factors for home epinephrine-treated reactions in 1100 OIT treatments (milk 710; peanuts 211; egg 52; sesame 57; and tree-nuts 70) from April 2010 to March 2019. A total of 121 patients experienced reactions at home that were perceived by them or their caregivers as severe enough to be treated with injectable epinephrine. Most epinephrine-treated reactions occurred during the first eight months of OIT. Their rate subsequently decreased as treatment progressed, but such reactions still occurred up to 2 years into treatment in occasional patients.

Milk-OIT was the most significant risk factor for such reactions on multivariate analysis. Among milk-treated patients, asthma comorbidity, emergency room visits due to a reaction before OIT, epinephrine-treated reactions during clinic up-dosing, and a lower tolerated dose at the beginning of OIT were significant risk factors for home epinephrine-treated reactions. Knowledge of these risk factors enables estimation of the risk of the individual milk allergic patient for such reactions. Among non-milk treated patients, male gender and a highest tolerated dose of <60 mg were the only significant risk factors for such reactions. While home epinephrine-treated reactions were associated with treatment failure in both milk and non-milk OIT, full desensitization was still achieved by nearly 74% in non-milk compared to only 18% in milk-treated patients.

The findings in this study may serve to identify milk-allergic patients who are at risk for home epinephrine-treated reactions and to direct them to alternative immunotherapy protocols.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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