• food allergy
• immunotherapy

With the increase in food allergy over the past few decades, there is demand for more than our existing management strategy—allergen avoidance (which is not 100% effective) and provision of rescue medication (which also is not always effective). Treatments such as oral immunotherapy (OIT) are not new, with at least one report in The Lancet from 1908.1 A century later, we are finally seeing larger, often multicentre studies report on outcomes. Indeed, OIT is offered routinely in many countries, including the USA, Spain, Italy, Israel and Japan. So why are we not offering OIT in routine practice yet?

The safety aspects of OIT were recently highlighted by Chu et al in a meta-analysis which included 1041 participants across 12 randomised controlled trials.2 As summarised by Archivist,3 although OIT induces desensitisation, patients who undergo OIT experience an increased rate of allergic reactions including anaphylaxis when on treatment. For peanut OIT, the risk of anaphylaxis increases threefold, with a relative risk of 3.12 (95% CI 1.76 to 5.55). In fact, this is likely to be an underestimate: there is such heterogeneity in how OIT studies report their outcomes and reluctance to share these data that it is difficult to accurately assess outcomes. For example, a Medical Research Council/National Institute for Health Research-funded study of peanut OIT in the UK, the STOP-2 study, did not report rates of anaphylaxis; one patient in the study self-administered intramuscular epinephrine on two occasions due to …