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. 2024 Feb 13;331(6):510-521.
doi: 10.1001/jama.2023.26857.

Management of Food Allergies and Food-Related Anaphylaxis

Edward G A Iglesia  1 , Mildred Kwan  2 , Yamini V Virkud  3 , Onyinye I Iweala  2   3
Affiliations

Management of Food Allergies and Food-Related Anaphylaxis

Edward G A Iglesia et al. JAMA. .

Abstract

Importance: An estimated 7.6% of children and 10.8% of adults have IgE-mediated food-protein allergies in the US. IgE-mediated food allergies may cause anaphylaxis and death. A delayed, IgE-mediated allergic response to the food-carbohydrate galactose-α-1,3-galactose (alpha-gal) in mammalian meat affects an estimated 96 000 to 450 000 individuals in the US and is currently a leading cause of food-related anaphylaxis in adults.

Observations: In the US, 9 foods account for more than 90% of IgE-mediated food allergies-crustacean shellfish, dairy, peanut, tree nuts, fin fish, egg, wheat, soy, and sesame. Peanut is the leading food-related cause of fatal and near-fatal anaphylaxis in the US, followed by tree nuts and shellfish. The fatality rate from anaphylaxis due to food in the US is estimated to be 0.04 per million per year. Alpha-gal syndrome, which is associated with tick bites, is a rising cause of IgE-mediated food anaphylaxis. The seroprevalence of sensitization to alpha-gal ranges from 20% to 31% in the southeastern US. Self-injectable epinephrine is the first-line treatment for food-related anaphylaxis. The cornerstone of IgE-food allergy management is avoidance of the culprit food allergen. There are emerging immunotherapies to desensitize to one or more foods, with one current US Food and Drug Administration-approved oral immunotherapy product for treatment of peanut allergy.

Conclusions and relevance: IgE-mediated food allergies, including delayed IgE-mediated allergic responses to red meat in alpha-gal syndrome, are common in the US, and may cause anaphylaxis and rarely, death. IgE-mediated anaphylaxis to food requires prompt treatment with epinephrine injection. Both food-protein allergy and alpha-gal syndrome management require avoiding allergenic foods, whereas alpha-gal syndrome also requires avoiding tick bites.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Iglesia reported receiving grants from the Robert Wood Johnson Foundation during the conduct of the study. Dr Kwan reported receiving grants from Pfizer QI outside the submitted work. Dr Iweala reported serving as on the advisory boards of Blueprint Medicines and Novartis and receiving consulting fees from Allakos Inc outside the submitted work; and was a coauthor of an article sponsored by Genentech. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Sensitization and Effector Phases in Food-Protein Allergy
MHC II indicates major histocompatibility complex class II; Tfh, T-follicular helper; Th2, T-helper 2.
Figure 2.
Figure 2.. Sensitization and Effector Phases in Alpha-Gal Syndrome
Other cells thought to be involved but not depicted include skin-resident dendritic cells, migrating dendritic cells, T-helper 2 cells, T-follicular helper cells, and invariant natural killer cells. Alpha-gal indicates galactose-α-1,3-galactose.
Figure 3.
Figure 3.. Tiered Avoidance Approach of Alpha-Gal–Containing Foods and Drugs
Alpha-gal indicates galactose-α-1,3-galactose.
See this image and copyright information in PMC

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