The management of food allergies has continued to evolve, from allergen avoidance to the use of oral immunotherapy (OIT) and recently available biologic therapy. Researchers at the 2024 AAAAI Annual Meeting presented data on several biologic therapies that could impact the treatment of patients with food allergies.

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

For the treatment of food allergies, we have done the most research on utilizing food-specific immunotherapy. OIT has been studied the most, but we have also looked at sublingual and epicutaneous immunotherapies, with the idea that small exposures to the food that a patient is allergic to can desensitize them and perhaps provide longer-term benefits. Across all 3 of these food-specific modalities, there does seem to be some efficacy, along with differing amounts of risk. One of the drawbacks is that they are everyday treatments, so it can be difficult for some patients to comply. Also, many of our patients whom we see in the clinic are allergic to more than 1 food. So, if a person is allergic to both peanuts and milk, for example, what do we do? Do we give these immunotherapies sequentially or simultaneously? How does that impact efficacy, treatment burden, and risk? These concepts underpin the desire and need for allergen-nonspecific treatments.

Multiple biologic therapies are being considered for the treatment of food allergies. However, the idea of using anything that is going to affect the immune system can be somewhat alarming to patients, with concerns about whether the immunotherapy is going to make them prone to influenza, COVID-19, cancer, or other types of illness or disease.

When trying to identify potential therapies, researchers look at a map of the allergic response process and try to identify where in the process we can target to stop an allergic reaction from happening. This can be anywhere from the very beginning all the way to the final step, when histamine is released. There is some concern that if you target earlier on in the allergic response process, you might potentially affect more targets and have more unintended side effects.

Dupilumab is an inhibitor of IL-4 and IL-13 signaling that is US Food and Drug Administration (FDA) approved for multiple other allergic diseases, including atopic dermatitis, asthma, and, recently, eosinophilic esophagitis. The early data in food allergies have been somewhat mixed, but they are being evaluated in several studies. Another biologic that is being considered includes the anti-TSLP agent tezepelumab. We will have to see what the benefits of these agents will be, but they have the potential to simultaneously treat multiple food allergies.

At the 2024 AAAAI Annual Meeting, there were a couple of novel therapies that were presented. An abstract by Croote et al studied IGNX001, an IgG4-based antibody treatment targeting the peanut allergen (abstract 387). We know that IgE is a key player when it comes to allergies. At the same time, we have also learned that IgG4 sometimes seems to play a protective role against food allergies. So, there is the thought that if you can use IgG4 to block the binding of the peanut allergen to IgE, you, in essence, can block the peanut allergen from causing any trouble. This is because it could potentially interfere with the IgE-mediated activation of and the histamine release from the mast cells and basophils. The study reported preclinical data showing that IGNX001 decreased mast cell activation using an in vitro test. So, there could be some potential there. One possible benefit is that the IgG4 that is put into the system could immediately start blocking the binding of the peanut allergen to the IgE that is present, and it may be effective quickly. This could lead to different strategies on how therapeutics are used for food allergy down the road.

Another abstract from the meeting presented preclinical data with MY006, a patient-derived antibody cocktail that is specific to the peanut allergen (abstract 390). Similar in concept to IGNX001, if the MY006 antibodies could be put into someone’s system quickly, they may quickly help protect someone from an allergic reaction, as opposed to taking multiple weeks or months.

Anti-IgE therapy is the biologic that is the furthest along in food allergies and is the easiest for patients and providers to intuitively understand. IgE is closer to the final step of the allergic process, sitting on the surface of mast cells and basophils and leading to histamine release. When it comes to anti-IgE therapy, specifically omalizumab, we have had 20-plus years of experience with this treatment. A huge perk of this approach is that there is a familiarity with how it works and how it is dosed, as well as reassurance that it seems pretty safe, even with long-term use.

One of the big presentations at the AAAAI meeting was the late-breaking abstract reporting on the results of the omalizumab OUtMATCH study, of which I was an investigator (abstract L54). In this study, patients had to be allergic to peanuts and to 2 other foods (ie, milk, eggs, cashews, walnuts, hazelnuts, or wheat) as measured by reactions to oral food challenges so that we could understand whether omalizumab is allergen nonspecific and works for multiple food allergies, not just peanuts. This study focused on the initial 4 months of treatment, whether with omalizumab or placebo. Afterward, oral food challenges were repeated to determine whether patients had achieved a clinically meaningful threshold of tolerance for each food. Nearly 67% of patients who received omalizumab were able to achieve that predefined threshold with peanuts. There were slight differences between the other foods, but the response for cashews was 41%, and the responses for milk and eggs ranged between 65% and 70%. These results confirmed what we were hoping would be the case: that anti-IgE therapy increases the reaction threshold across multiple foods after at least 4 months of treatment. One medicine (ie, omalizumab) could therefore be used to manage multiple food allergies plus other approved allergic diseases in patients aged 1 year and older. I do feel like it is going to be something that I discuss with many of my patients with food allergies.

We have had some major pluses, but the work is definitely not done. These treatments can desensitize and decrease reactivity, but we still need to work toward a cure so that our patients can ultimately be free to eat without worry.