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Triggers for home epinephrine-treated reactions during OIT

Published: December 31, 2021

The documented efficacy of Oral Immunotherapy (OIT) for food allergy has led to its gradually spreading use in recent years. However, anaphylactic reactions, particularly those treated with injectable epinephrine, occurring to home doses, are a major safety limitation, and might lead to treatment failure. These reactions occur to doses which were previously consumed safely, and their triggers are of major importance.

In a study published in The Journal of Allergy and Clinical Immunology: In Practice, Nachshon et al examined triggers for home epinephrine-treated reactions (HETRs) in 1270 OIT treatments (milk 780; peanuts 256; egg 63; sesame 72 and tree-nuts 99) performed for patients older than 3.7 years, from April 2010 to March 2018. Information was collected from the documentation in patients' files and their daily reports transmitted by email and via a web reporting system, during the build-up phase of their OIT treatment.

Overall, 270 HETRs were experienced in 200 OIT patients, (in 70 more than once). The leading identified triggers for HETRs were physical exercise temporally associated with administration of home dose (20%), and dose consumption during concurrent illnesses (16.7%), or when fatigued (13.8%). Monthly variability of HETRs throughout the year was observed, with a maximal frequency in April and August and fewest in February, possibly attributed to spring pollen season or to national holidays and summer vacation periods. Most HETRs (152/270=56.3%) occurred to doses <500 mg protein and most (n=124, 81.6%) of these 152 reactions occurred to doses ≤300 mg protein. The occurrence of HETRs decreased with increasing doses, however, such reactions still occurred even at doses >2500 mg protein. In addition, the occurrence of first HETRs was highest (35.5%) during the first and decreased to 13.8% by the last of the four-weeks home-treatment phase. Second HETRs occurred in a similar rate throughout these 4-week period.

The findings of this study are intended to help both patients and caregivers in minimizing the risk for HETRs and improving OIT safety

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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