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. 2022 Jun;77(6):1863-1872.
doi: 10.1111/all.15212. Epub 2022 Jan 15.

Cashew oral immunotherapy for desensitizing cashew-pistachio allergy (NUT CRACKER study)

Arnon Elizur  1   2 , Michael Y Appel  1 , Liat Nachshon  1   3 , Michael B Levy  1 , Naama Epstein-Rigbi  1   2 , Yael Koren  1 , Marie Holmqvist  4 , Helena Porsch  4 , Jonas Lidholm  4 , Michael R Goldberg  1   2
Affiliations

Cashew oral immunotherapy for desensitizing cashew-pistachio allergy (NUT CRACKER study)

Arnon Elizur et al. Allergy. 2022 Jun.

Abstract

Background: Oral immunotherapy (OIT) is a treatment option for patients with milk, egg, and peanut allergy, but data on the efficacy and safety of cashew OIT are limited.

Methods: A cohort of 50 cashew-allergic patients aged ≥4 years, who were consecutively enrolled into cashew OIT (target dose 4000 mg protein) between 4/2016 and 12/2019. Fifteen cashew-allergic patients who continued cashew elimination served as observational controls. Co-allergy to pistachio and walnut was determined. Full desensitization rate and associated immunological changes in both groups were compared. Patients fully desensitized to cashew were instructed to consume a dose of 1200 mg cashew protein for 6 months and were then challenged to a full dose. Patients with co-allergy to pistachio or walnut were challenged to the respective nut.

Results: Forty-four of 50 OIT-treated patients (88%) compared to 0% in controls tolerated a dose of 4000 mg cashew protein at the end of the study (odds ratio 8.3, 95% CI 3.9-17.7, p < 0.001). An additional three patients were desensitized to 1200 mg cashew protein, and three patients stopped treatment. Three patients (6%) were treated with injectable epinephrine for home reactions. Desensitized patients had decreased SPT, sIgE, basophil reactivity, and increased sIgG4, following treatment. Following cashew desensitization, all pistachio (n = 35) and four of eight walnut co-allergic patients were cross-desensitized to the respective nut. All (n = 44) patients consuming a low cashew dose for ≥6 months following desensitization passed a full-dose cashew OFC.

Conclusions: Cashew OIT desensitizes most cashew-allergic patients and cross-desensitizes to pistachio. Safety is similar to OIT for other foods.

Keywords: allergy; cashew; cross-reactivity; immunotherapy; tree nuts.

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References

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