Safety and Efficacy Balance of Baked Milk and Egg Oral Immunotherapy

Opinion statement

Purpose of review There is a subgroup of individuals with egg or cow's milk (CM) allergy that can tolerate heated egg or CM. Thermal processing has been shown to affect antigen allergenicity either directly by denaturation of significant epitopes, or indirectly by synergistically altering their susceptibility to the digestion process under specific pH conditions. CM and egg proteins have heat labile molecules that become hypoallergenic after thermal treatment. The allergenicity may be further reduced when the CM and egg allergens are interacting with wheat proteins, and in particular gluten, in an interplay that teleologically affects solubility and therefore bioavailability. This phenomenon is known as the food matrix effect. By exploiting these observations, it has been suggested that diets containing extensively heated CM and egg might comprise an oral immunotherapeutic approach that could alter the expected natural allergy resolution or immunomodulate to tolerance the cases with persistent allergy.

Recent findings There is evidence suggesting that most of the baked-tolerant patients can be benefited from baked CM or egg oral immunotherapy (OIT). Following this approach, these patients can be desensitized, can be promoted to a transition from baked CM/egg OIT-induced tolerance to unheated CM and egg OIT-induced tolerance, or may acquire sustained tolerance.

Summary Baked CM or egg OIT may accelerate CM or egg allergy resolution and therefore may be a new therapeutic option to etiologically and not just symptomatically treating CM and egg allergy. It remains to be appropriately studied which are the phenotypic characteristics of these patients and which will be the appropriate immunotherapeutic protocol so that OIT can be easily and safely be offered to them.

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