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”.