Food-Dependent Exercise-Induced Anaphylaxis

Abstract

Food-dependent exercise-induced anaphylaxis (FDEIA) is a form of anaphylaxis that occurs associated with exercise, in which symptoms develop by the combination of food ingestion and physical activity. We aimed to review and discuss the main clinical recommendations for management of FDEIA, focusing on individual factors. New diagnostic strategies have been developed to optimize the accuracy of provocation challenges, taking in consideration augmenting factors, such as alcohol or non-steroidal anti-inflammatory drugs. However, FDEIA is still insufficiently diagnosed and a high index of clinical suspicion is usually required. Management is complex and based on preventing the reaction and education of the patient, followed by treatment of the acute episode. Several pharmacological strategies for prophylactic treatment have been proposed; however, they are based mainly in low quality of evidence. For management of FDEIA, the culprit food allergen should be avoided at least 4 h before exercise and the individual needs to be educated on how to practice exercise in safe conditions, particularly recognizing the importance of stopping exercise or physical activity at the earliest manifestation of symptoms. This prevention strategy should be developed accordingly to the specific characteristics of the individual and food allergen involved. Due to the difficulty in avoiding and preventing a reaction, pharmacological prophylactic treatment options, namely antihistamines, montelukast, oral cromolyn sodium, misoprostol, and omalizumab, have been proposed. However, they do not replace current recommendations. The risk and quality-of-life impact of FDEIA warrants more accurate diagnostic tools and management strategies. The improvement on the knowledge of the mechanisms mediating FDEIA will help to find new prevention and treatment targets.