LAUSR

Food allergy is a common disease especially in childhood, affecting up to 6% of children in Europe.1 Currently, there is no cure for foodallergic patients. Guidelines for the management of food allergy consist of a strict allergen avoidance diet and emergency treatment in case of accidental reactions, which happen frequently.2 Therefore, food allergy has a major impact on the quality of life of children and their caregivers. Over the last years, much research has been conducted on immunotherapy as a causal treatment option for food allergy. Most studies so far investigated on oral immunotherapy (OIT), which seems an effective method to induce desensitization in most patients. However, many patients undergoing OIT experience adverse events (AEs), preventing some patients to achieve their target dose. Despite the fact that most of this reactions are considered as mild (ie, oral itching or abdominal pain), some patients suffer from severe AEs affecting the upper respiratory tract and up to 36% of children in OIT studies discontinued due to recurrent or significant AEs.3,4 A recent systematic review and metaanalysis on OIT trials for food allergy revealed that the risk of experiencing systemic adverse reactions was higher in patients receiving OIT, with a marked increased risk of local adverse reactions.5 Therefore, optimized protocols for OIT are of major interest especially to improve the safety profile. Next to alternative routes of application as sublingual and epicutaneous immunotherapy or the use of hypoallergenic products, i.e., baked products or recombinant proteins, OIT trials in combination with adjuvants such antiIgE are studied. AntiIgE by itself was used as a nonallergenspecific treatment for peanut allergy in clinical trials.6,7 In the first published trial using TNX901, the threshold dose to peanut during the posttreatment oral food challenge could be increased in patients receiving antiIgE.6 However, about 25% of the patients did not show an increased threshold suggesting some patients being treatment nonresponders. Currently, the only antiIgE antibody approved for clinical use by the FDA and EMA is Omalizumab with the clinical indication of severe allergic asthma or chronic urticaria. Omalizumab is a recombinant, humanized, monoclonal antibody binding on free serum IgE antibodies and consequently preventing their binding on the highaffinity IgE receptor, FcεRI, on effector cells as mast cells and basophils. First studies investigated the treatment of antiIgE in combination with OIT, which are summarized by Lin et al in the current issue of this journal. As pointed out by the authors, the major benefits of Omalizumab combined with OIT were a faster desensitization (faster achievement of the target maintenance dose) and an improved safety profile (lower number of AEs) compared to OIT alone. However, these findings are based on only seven studies with a relatively small number of patients, and only two of those trials were placebocontrolled. Similar to the fact that there is still no consensus on regular OIT protocols without adjuvants (ie, starting or maintenance dose, escalation schedule, duration of escalation, or maintenance phase), optimal protocols for a welldefined timing and duration of antiIgE treatment combined with OIT still need to be established. Both limitations are mainly due to the high diversity in protocols and in reporting results especially on safety in performed trials. The EAACI is about to establish guidelines for allergen immunotherapy for IgEmediated food allergy, which might be helpful to harmonize future OIT protocols. As for OIT alone, sustained unresponsiveness as a longterm efficacy outcome has to be investigated for the combined treatment of OIT with antiIgE.