Efficacy of baked milk oral immunotherapy in baked milk-reactive allergic patients

Oral immunotherapy (OIT) has shown overall benefit in desensitizing many patients with persistent IgE-mediated food allergy. Still, the treatment is not without adverse reactions. In a large OIT milk treatment program conducted in Israel, approximately 15% of patients were unable to follow it to completion because of IgE-mediated reactions. Some patients with allergy to unheated milk or egg tolerate such foods when they are heated, as heating likely induces conformational changes to a number of the epitopes responsible for IgE binding.

Goldberg et al present a study of 14 children who failed unheated- or unbaked-milk OIT who received OIT with baked milk testing the hypothesis that this might result in desensitization to to unheated milk as well (J Allergy Clin Immunol 2015; 136(6): 1601-1606). Only three of the children tolerated the primary outcome dose of 1.3 g of baked milk protein, and eight out of the other 11 experienced IgE-mediated reactions, including two patients with anaphylactic episodes requiring intramuscular epinephrine. The three children who reached the 1.3 g baked milk dose were able to tolerate up to 900 mg of unheated milk at the end of the study, and all patients remaining in the program through 12 months demonstrated an increase in tolerance to unheated milk The authors also provide evidence that a basophil activation test, comparing patient reactivity to heated or unheated milk, could prospectively distinguish between patients succeeding or failing to complete the program.

The study contributes to our understanding of the benefits and risks of OIT, which continue to be under close scrutiny. The results indicate caution is required, and more work must be done before baked milk OIT is used freely in milk-reactive patients.