There are several treatment pathways that are available to patients with food allergies, but patients with food allergies who receive treatment may still require rescue epinephrine. Several presentations at the American College of Allergy, Asthma & Immunology (ACAAI) 2024 Annual Scientific Meeting addressed emerging treatment options for food allergies and novel pathways for the delivery of rescue epinephrine.

Following these presentations, featured expert Brian P. Vickery, MD, was interviewed by Conference Reporter Associate Editor-in-Chief Mona Shah, PharmD. Dr Vickery’s clinical perspectives on these findings are presented here.

I was excited to see the recent US Food and Drug Administration (FDA) approval of an intranasal, needle-free epinephrine device for the treatment of allergic reactions, which is something that has been celebrated by patient advocates and individual patients, and this product is now starting to make its way into the marketplace. The idea is that if we can deliver epinephrine by a noninjectable route, people might be more inclined to use it when it is needed rather than deciding not to use it because they do not want to inject themselves or their child. Epinephrine nasal spray is FDA approved for situations in which epinephrine is indicated in patients who weigh 66 pounds or more. I always remind patients that the FDA approval was based on pharmacokinetic/pharmacodynamic data showing equivalent blood levels following nasal administration vs intramuscular administration, and that clinical outcome data among patients experiencing anaphylaxis are lacking at this time. Since blood levels were comparable, the thought is that epinephrine nasal spray probably works about as well as intramuscular autoinjectors, but, obviously, placebo-controlled trials in patients experiencing anaphylaxis are not feasible or ethical.

Some exciting data presented at the ACAAI 2024 Annual Scientific Meeting really help us in this regard. One poster looked at intranasal epinephrine in patients with allergic rhinitis after doing a nasal allergen challenge. The concern there was that if the nose is swollen shut as part of the allergy you are trying to treat with the spray, will it work? They found that the nasal epinephrine spray actually resulted in higher mean epinephrine concentrations for up to 240 minutes compared with intramuscular epinephrine (abstract R239). Sometimes, food allergic reactions can cause quite profound nasal congestion. And, while this study was not quite in that same context, it starts to get at the question of whether intranasal epinephrine administration is affected by active allergic inflammation at the site of administration, which is pretty reassuring.

Another abstract from the ACAAI meeting included a small number of patients with food allergies who received nasal epinephrine after having moderate anaphylaxis following an oral food challenge (OFC; abstract R240). Researchers found mean epinephrine concentrations to be similar to what has been found with intramuscular epinephrine, with a median time of 16 minutes to resolve moderate anaphylaxis symptoms and no patients requiring a second dose, although one patient did have a biphasic reaction requiring intramuscular epinephrine. While these are small proof-of-concept studies, they are helpful to me for when I am talking with my patients because people want to know if intranasal epinephrine could be a viable alternative to intramuscular epinephrine.

The FDA-approved biologic omalizumab was discussed in an oral presentation titled “Biologics in Food Allergy – Part I: Evidence and Benefits” at the recent ACAAI 2024 Annual Scientific Meeting. The large, well-powered, rigorous, phase 3, randomized, controlled OUTMATCH trial demonstrated that desensitization to one or more foods could be achieved with omalizumab. This is now available in the clinic for patients who desire such an option, based on shared decision making. However, although omalizumab achieves desensitization, it is not a cure for food allergies and must be continued indefinitely. It may be of particular interest to patients who have multiple food allergies, in whom oral immunotherapy (OIT) can be very difficult and allergic events are expected, or when OIT is not tolerated.

We are also looking at follow-up studies of the practical application of omalizumab in the clinical setting, such as the poster by Ghinwa Al Hassanieh, MD, and colleagues presented at the ACAAI meeting (abstract R261). This study demonstrated that the use of omalizumab in combination with OIT does not appear to be incompatible, and this is also currently being assessed in the second part of the OUTMATCH trial. The field will need to continue studying this more, and I think that this is an area of emerging interest that may be a likely clinical scenario for patients who begin omalizumab therapy. It is important to note that the approved labeling for omalizumab states that it is supposed to be used with ongoing allergen avoidance. Similarly, OIT is intended to be used with ongoing avoidance.

There were a couple of case reports presented at the ACAAI 2024 Annual Scientific Meeting of patients receiving treatment with the biologic dupilumab for their eczema who also seemed to have improvements in their food allergy symptoms while on therapy (abstracts M327 and M332). However, I am not really optimistic about dupilumab for the treatment of food allergies because the summary data from one currently unpublished trial found that patients with peanut allergies who were randomized to dupilumab or placebo and underwent OFCs at the beginning of the study and again at 6 months showed no significant difference in peanut reactivity at the 6-month OFC. This suggests that, although dupilumab affects IgE levels, it does not affect sensitivity levels, and no additional studies are currently planned to develop this therapy for food allergies.