Exploiting nut cross-reactivity to facilitate real-world treatment of tree nut allergy

Abstract

Oral immunotherapy (OIT) for food allergy has become increasingly common among practicing allergists. 1 Wasserman RL Jones DH Windom HH Meeting FacultyReaching for best practices in food oral immunotherapy: report on the second annual Food Allergy Support Team meeting. Ann Allergy Asthma Immunol. 2019; 123: 129-130 Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Tree nut allergy accounts for approximately 33% of food-induced anaphylaxis fatalities and only 9% outgrow their allergy. 2 Bock SA Munoz-Furlong A Sampson HA Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007; 119: 1016-1018 Abstract Full Text Full Text PDF PubMed Scopus (749) Google Scholar ,3 Fleischer DM Conover-Walker MK Matsui EC Wood RA The natural history of tree nut allergy. J Allergy Clin Immunol. 2005; 116: 1087-1093 Abstract Full Text Full Text PDF PubMed Scopus (223) Google Scholar Tree nut OIT has been successful 4 Bégin P Winterroth LC Dominguez T et al. Safety and feasibility of oral immunotherapy to multiple allergens for food allergy. Allergy Asthma Clin Immunol. 2014; 10: 1 Crossref PubMed Scopus (102) Google Scholar ,5 Elizur A Appel MY Nachshon L et al. Walnut oral immunotherapy for desensitisation of walnut and additional tree nut allergies (nut cracker): a single-centre, prospective cohort study. Lancet Child Adolesc Health. 2019; 3: 312-321 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar but is burdened by frequent sensitization, as assessed by positive specific immunoglobulin or skin prick tests to multiple nuts, often without a previous exposure history. Although allergy to each nut could be confirmed or refuted by an oral food challenge (OFC) and OIT performed to each reactive nut, such an approach is not only onerous for patients, but each challenge carries the risk of a serious reaction. Although simultaneous treatment with multiple nuts has been successful, 4 Bégin P Winterroth LC Dominguez T et al. Safety and feasibility of oral immunotherapy to multiple allergens for food allergy. Allergy Asthma Clin Immunol. 2014; 10: 1 Crossref PubMed Scopus (102) Google Scholar each nut added to the treatment increases the complexity for patients and for treating allergists. In addition, increasing the number of nuts treated increases the maintenance dose, further increasing the burden for patients. Cashew and pistachio nuts are known to be cross-reactive, as are walnuts and pecans, and walnut OIT has been found to partially or fully desensitize some patients to other nuts. 5 Elizur A Appel MY Nachshon L et al. Walnut oral immunotherapy for desensitisation of walnut and additional tree nut allergies (nut cracker): a single-centre, prospective cohort study. Lancet Child Adolesc Health. 2019; 3: 312-321 Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar , 6 Smeekens JM Bagley K Kulis M Tree nut allergies: allergen homology, cross-reactivity, and implications for therapy. Clin Exp Allergy. 2018; 48: 762-772 Crossref PubMed Scopus (39) Google Scholar , 7 Elizur A Appel MY Nachshon L et al. NUT Co Reactivity – Acquiring Knowledge for Elimination Recommendations (NUT CRACKER) study. Allergy. 2018; 73: 593-601 Crossref PubMed Scopus (65) Google Scholar