Moving beyond desensitization to tolerance in food allergy.

Abstract

Management of IgE-mediated food allergy is shifting from reactive management strategies (allergen avoidance and ready access to autoinjectable epinephrine in case of exposure) to proactive therapies. These therapies are in various stages of clinical development and implementation; the two main approaches include allergen-specific/active therapies (induce the immune system to produce a protective response to the allergen; e.g., FDA-approved AR101/Palforzia for peanut allergy), and allergen-agnostic, passive therapies (provide the body with the tools needed to suppress immediate hypersensitivity reactions in a non-specific manner; e.g., FDA-approved omalizumab/xolair). These therapies provide a similar degree of protection, specifically desensitization (increased reaction threshold while receiving food allergy therapy, "bite safety"), but differ in mechanisms, dosing protocols and side effects. The goals of therapeutics in development are shifting to sustained unresponsiveness/remission (absence of clinical reactivity after allergen and food allergy therapy avoidance, typically for weeks to months) and tolerance (no clinical reaction/free ingestion of the allergen). As the food allergy management repertoire expands, important considerations in selecting a therapy will be patient-specific and include mode of delivery, dosing regimens, side effect profiles and goals/outcomes. The role of shared decision making and implementation strategies to support equitable access across patient populations and clinical contexts will be critical to move an increasing number of patients beyond desensitization to tolerance, if they wish.