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Oral immunotherapy (OIT) is a recent and evolving therapeutic option for the treatment of immunoglobulin E (IgE) mediated food allergies. Clinical practice guidelines are starting to emerge to establish the parameters of this new clinical offer. A comparative analysis reveals several areas of consensus, such as the need for an accurate diagnosis with immunoglobulin E testing and, if necessary, open food challenge before initiating therapy; a list of specific contraindications; the importance of performing OIT in an adequate setting with appropriate level of expertise; the possibility to use grocery products to perform OIT; and the need to adapt protocols to patient needs. Certain discrepancies among the guidelines also underscore various areas of uncertainty, which makes it important that decisions to pursue the treatment be reached by using a shared decision-making approach that involves patients and caregivers. Gaps of knowledge remain with regard to treatment of adolescents and adults, and optimal performance measures in practice. These guidelines are expected to evolve in the coming years as new scientific and experiential knowledge is gained.

Background: Abdominal pain is a frequent symptom of IgE-mediated food allergy with limited therapeutic options. Visceral smooth muscle cell relaxation can be induced by activation of the beta-adrenergic receptors. Objective: To evaluate the efficacy of inhaled salbutamol empirically used to relieve abdominal pain caused by IgE-mediated allergic reactions at one center. Methods: All double-blind placebo-controlled food challenges to peanut performed at CHU Sainte-Justine between 2016 and 2020 were reviewed to identify patients that presented abdominal pain as part of their reaction. The primary outcome measure was the delay between the initiation of therapy and improvement of abdominal pain. It was compared between patients that had received inhaled salbutamol as part of their treatment and those that did not. Linear regression was performed to control for potential confounders. Results: During the study period, 174 positive DBPCFCs were performed, including 116 for peanut allergy. Of these, 77 presented abdominal pain and 49 met the criteria for inclusion in the study. Patients that received salbutamol improved significantly faster (median 14 minutes; range 5-66) than those that did not (61 minutes range 5-194) (p<0.0001). In the linear regression, only the administration of salbutamol and emesis were found to independently accelerate the recovery of abdominal pain, each reducing the time to improvement by an average of 61 ±10 minutes (p<0.0005) and 44 ±13 minutes (p<0.0005), respectively. Conclusion: This retrospective study provides low-quality evidence of a large effect for salbutamol in the treatment of gastro-intestinal anaphylaxis. Further investigation in randomized controlled trials would be warranted.

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