Food immunotherapy practice: Nation differences across Europe, the FIND project

Abstract

Background: Food allergen immunotherapy (FA-AIT) practice is known to vary globally. This project aims to identify and characterize European centres performing FA-AIT.Methods: An EAACI task force conducted an online survey to gather relevant information regarding FA-AIT practice and setting-specific resources after reviewing the published literature and congress abstracts throughout Europe. | 921RodRíguez del Río et al. | INTRODUC TI ONFood allergy affects millions of patients worldwide 1 and significantly impacts quality of life secondary to severe allergic reactions, economic burden and dietary restrictions. [2][3][4][5][6] Until recently, the standard of care was limited to trigger avoidance and the use of educational tools and rescue medication to minimize the risk associated with accidental exposure. Food allergen immunotherapy (FA-AIT) is an encouraging alternative; however, after decades of research, 7 existing limitations regarding safety, long-term efficacy, and cost-effectiveness fuel debates as to whether it is ready for use in Results:We identified 102 FA-AIT centres in 18 countries; only Spain (n = 39) and France (n = 16) had ≥10 such centres. Overall, most facilities were hospital-based (77.5%), publicly funded (80.4%) and delivered FA-AIT as routine clinical care (80.4%).On average, departments had 3 allergists/paediatric allergists and 2 nurses. Surveyed centres had provided FA-AIT for a median of 9 years [1-24] to a median of 105 patients. The estimated total number of treated patients was 24875, of whom 41.3% received AIT for milk, 34.2% egg, 12.8% peanut and 11.7% other foods.Anaphylaxis to AIT doses requiring over 4-6 h of observation was reported by 70.6% of centres, ICU admissions by 10.8% and eosinophilic esophagitis by 45.1%. Quality of life and sustained unresponsiveness were evaluated in 20.6% and 54.9% of centres, respectively. The main contraindications for food AIT were severe asthma (57%-63%), eosinophilic esophagitis (56%-48%) and age below 5 years (47%-41%). Conclusions:In Europe, FA-AIT is provided mostly in clinical practice. Significant variation is seen in the number of centres per country, facility characteristics and inclusion/exclusion criteria, and in certain aspects of protocols. Potential inequality in access to AIT has been identified as well as the need for education and guidance for treatment standardization.

An update on recent developments and highlights in food allergy

“…The USA 162 and Europe recently approved the first pharmaceutical product for the treatment of PA in children aged 4-17 years. Approaches in other countries 163,164 support the use of foods for OIT. Debate about the best application of OIT continues, with concerns about the risk of severe allergic reactions due to OIT itself needing to be balanced against possible reduction in reactions from accidental exposure (Figure 4).…”

Information needs of patients considering oral immunotherapy for food allergy

“…OIT has been evaluated primarily in paediatric populations, through phase 2/3 clinical trials and real‐world studies, while data in adults are very limited 11–13 . With the recent approval by European and USA regulators of Palforzia®, there are now commercial and non‐commercial forms of OIT available for use in several countries 12,14–16 . While OIT has consistently been shown to induce desensitization, it has rarely been shown to be curative; thus, long‐term adherence to potentially daily, indefinite therapy may be required 9 .…”

“…This strategy is common for OIT to milk and egg in Europe although many other providers may take this approach for other foods with a wide variation in target doses reported 10,13,15,28 . For example, in European clinical practice, the mean maintenance doses for OIT to cow's milk and egg are similar (3581 mg and 3268 mg protein, respectively), but significantly higher than for peanut (1290 mg peanut protein, p < .05) 16 …”

Trends in food allergen immunotherapy in Korea after changed national regulations

“…According to these guidelines, OIT is a recommended treatment option for children with egg, milk, and peanut allergies to increase the threshold of reaction while on treatment but not as a treatment option for children with the goal of post-discontinuation effectiveness [ 3 ]. Thus, OIT using milk/egg/peanut in outside research settings has been allowed in most of Europe with the exception of Germany and the Netherlands [ 4 ]. According to the GA2LEN guideline, peanut EPIT using licensed pharmaceutical products is also suggested if it becomes available to increase the amount of peanut tolerated during therapy.…”

“…The clinical trends in FA-AIT also differ among countries and have changed rapidly. A large-scale online survey of the real clinical practices of allergists who administer OIT was conducted in the US in 2014 [ 2 ], Japan in 2018 [ 5 ], and Europe in 2022 [ 4 ]. In the US, 10.1% of allergists responded and 13.8% of respondents provided OIT [ 2 ].…”