To the Editor
We have read with great interest the article by Muraro et
al1 which deals with the update of the EAACI guideline
on anaphylaxis. In their box 4, the authors1 divide
the indications for the prescription of self-injectable adrenaline into
two categories: a) ”Absolute indications for adrenaline autoinjectors”;
b) ”Consider prescribing adrenaline autoinjectors”. In this second
category, the authors included oral immunotherapy (OIT) for food allergy
(FA), explaining that anaphylaxis is a known adverse effect of OIT for
food allergy and supporting this categorization by citing the EAACI
guidelines on allergen immunotherapy: IgE-mediated food allergy of
20182. However, in this last guideline2 and in particular in the box 7 (”General
considerations before initiating FA-AIT”) we read ”Patients and their
families should be motivated, adherent, and capable of administering
emergency treatment (including intramuscular adrenaline) in case of
adverse effects”. In addition, in the box 12 2(”Summary of the management”) we read that, in addition to other
measures, the physician who decides to start an OIT for AF must not
forget the ”Provision of emergency kit with copy of emergency action
plan and adrenaline auto-injector for treatment of anaphylaxis”.
It would seem, in conclusion, that the EAACI 2018 guideline considers
the prescription of the adrenaline auto-injector in case of OIT for FA
to be essential, while the EAACI 2021 guideline considers it optional,
to be taken into consideration, to think about it, but certainly not to
be placed among the absolute indications. The change of this
recommendation appears inexplicable, especially by the same scientific
society, with some authors signing both documents and with the choice to
support this variation with a reference that expresses itself
differently.
Moreover, if we consider recent evidences in this regard, they seem to
adopt the maximum prudence. The systematic review of Chu et al3 concludes: ”In patients with peanut allergy,
high-certainty evidence shows that available peanut oral immunotherapy
regimens considerably increase allergic and anaphylactic reactions over
avoidance or placebo”.