Chart review supports expansion of subcutaneous immunotherapy, oral food challenges
Key takeaways:
- 0.13% of subcutaneous immunotherapy injections led to systemic reactions.
- 15.8% of systemic reactions in SCIT were anaphylaxis.
- 248 of 2,360 patients who had an oral food challenge experienced anaphylaxis.
SAN DIEGO — A retrospective chart review of patients with allergy who participated in subcutaneous immunotherapy and oral food challenges suggested that these therapies should be expanded, according to a pair of posters presented here.
The benefits of these strategies as well as the safety profile of subcutaneous immunotherapy (SCIT) drove this recommendation, A.J. Stephens, a third-year undergraduate student at the University of Hawaii at Manoa, said at the 2025 American Academy of Allergy, Asthma & Immunology/World Allergy Organization Joint Congress.
“The benefits of SCIT are to act as a potentially disease-modifying treatment as well as an improvement in the quality of life for patients,” Stephens told Healio.
Patients who are offered SCIT already have tried other therapies such as antihistamines, nasal sprays, inhalers and allergen avoidance, she continued, but their allergies still are not well managed.
“SCIT has long-lasting benefits for improving asthma, allergies and atopic dermatitis,” Stephens said.
Also, Stephens added, OFCs are beneficial in confirming food allergies as well as in allowing patients to incorporate more foods into their diet, especially if these diets are limited due to excessive allergies and/or intolerances.
The data included 1,703 patients (mean age, 34.1 years; 56.6% female; 64.5% white) who received SCIT via 60,725 injections between Jan. 1, 2018, and Dec. 31, 2023, at an allergy and immunology practice affiliated with an academic medical center.
“Patients were treated for environmental allergies such as trees, grass, weeds, mold, dust and animal dander,” Stephens said.
Systemic reactions followed 0.13% of these injections, and 15.8% of these systemic reactions were anaphylaxis, defined as World Allergy Organization (WAO) grade 3a or higher. Also, 57% of patients who went to the ED had anaphylaxis based on WAO criteria.
Among the patients who experienced anaphylaxis, 13.2% received an injection from a new vial, 5.3% received cluster SCIT, 51.3% had comorbid asthma and 28.9% had a history of previous systemic reactions.
“There was a higher likelihood of a systemic reaction in patients receiving SCIT who had asthma, especially if it was poorly controlled,” Stephens said.
Before patients received injections, the office assessed asthma control to minimize this risk, she said.
“In addition, patients who had one systemic reaction were more likely to experience a second reaction,” Stephens said. “For this reason, any patient who had experienced a prior systemic reaction had to self-carry epinephrine at their appointments.”
Treatment for anaphylaxis included epinephrine for 88.2% of the group, antihistamines for 88.2%, corticosteroids for 55.6% and albuterol for 34.2%. The median time from anaphylaxis onset to administration of epinephrine was 5 minutes.
The review also examined data from 2,360 patients (mean age, 7.8 years; 54.4% male; 56.9% white; 18.5% with comorbid asthma) at the practice who had an OFC between Jan. 1, 2018, and June 30, 2024.
“The most commonly challenged foods were tree nuts, peanuts, milk, baked milk, egg, baked egg, sesame and wheat,” Stephens said.
The median time from the start of the OFC to the onset of anaphylaxis for the 248 patients who experienced it was 16 minutes.
“Anaphylaxis during an OFC commonly occurred in young children who were already allergic to at least one food or if they were being challenged with similar allergens, such as cashew and pistachio,” Stephens said. “Cutaneous and upper respiratory symptoms were also signifiers of a systemic reaction developing, as well as vomiting in young children.”
Reactions included cutaneous symptoms (65.3%), upper respiratory symptoms (44%) and gastrointestinal symptoms (29.8%), with 62% experiencing reactions involving two organ systems and 8.9% experiencing reactions involving three or more organ systems.
Based on WAO criteria, 42.3% of reactions were grade 1, 51.6% were grade 2, 4.4% were grade 3 and 0.4% were grade 4.
Treatments for patients with anaphylaxis included epinephrine (60.1%), antihistamines (95.6%) and corticosteroids (32.9%), with 2.8% transferred to the ED. Median times from the onset of anaphylaxis to epinephrine administration included 6 minutes for WAO anaphylaxis grades 1 or 2 and 4 minutes for WAO anaphylaxis grades 3 and 4.
Considering the benefits and safety profile of SCIT as well as the benefits of OFCs for patients with food allergy, the researchers encouraged allergists and immunologists to expand the routine use of these strategies when appropriate.
Stephens noted that even though OFCs may provoke anxiety at first, they still are important.
“Many patients are nervous about trialing a food they have previously avoided due to a negative reaction,” Stephens said. “This fear of accidental ingestion can be mitigated in two ways.”
First, Stephens suggested, patients who pass OFCs with no reaction may be able to introduce these foods into their diet safely, which could be “monumental” for patients with restrictive diets because of multiple allergies.
Second, reactions during OFCs are not failures since they are promptly treated, she said.
“This shows the patient the efficacy of their self-administered epinephrine, reducing their fear around the ‘what-ifs’ of accidental ingestion,” Stephens said. “It also reinforces that their strict avoidance of their allergens and label-warning is warranted.”
Stephens said that physicians can use these findings to better inform patients about the safety of SCIT and OFCs.
“The rate of systemic reactions, and especially severe reactions, is incredibly low, and allergy and immunology offices are well prepared to immediately treat any reaction,” she said. “Before starting a food challenge or SCIT is administered, vitals are taken, and the general health of the patient is assessed to make sure they are well.”
Next, SCIT and OFC research should investigate triggers behind systemic reactions, Stephens suggested.
“For example, we were interested in looking into seasonality. Are patients receiving SCIT for tree pollen more likely to have a systemic reaction during the pollen season for that tree species? What factors are likely to indicate a patient will have a negative food challenge?” she said.
“Although patients undergoing an OFC usually are blood and skin tested beforehand, the relationship between these tests and the result of the OFC is still being looked into,” she added.
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For more information:
A.J. Stephens can be reached at aj.stephens03@gmail.com.