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allergy.food-allergy.core.v1PRODUCTION
allergy.food-allergy.core.v1

IgE-mediated food allergy

allergychronicsyndromeadultpediatric
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Encounter flow

12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Frame as a CHRONIC IgE-mediated reactivity managed through avoidance + emergency action plan + auto-injector, with optional disease-modifying immunomodulatory therapy (peanut OIT, omalizumab) per EAACI 2025. Acute reactions route to allergy.anaphylaxis.v1.

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Actions
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Advance rule
Set
Advance when

Chronic FA framing set; rescue route to anaphylaxis engine noted

Patient inputs (10)

Eczema, asthma, allergic rhinitis define the atopic background; uncontrolled asthma raises anaphylaxis fatality risk (EAACI 2025 PMID 39473345)

Reproducibility, latency from ingestion, organ systems involved, severity, and presence of cofactors (exercise, NSAIDs, alcohol) define the pretest probability before sIgE/SPT (EAACI 2025 PMID 39473345)

Possession + in-date + technique competence are core safety outcomes; two devices recommended for at-risk patients (EAACI 2025 PMID 39473345)

Peanut OIT (Palforzia) FDA-approved age 1-17; omalizumab labelled from age 1; LEAP early-introduction window is 4-11 mo (EAACI 2025 PMID 39473345)

Uncontrolled asthma is a relative contraindication to peanut OIT and a major modifier of anaphylaxis risk; achieve control before disease-modifying therapy (EAACI 2025 PMID 39473345)

Elevated baseline tryptase (>=11.4 ng/mL) flags mastocytosis/HAT and raises anaphylaxis fatality risk; obtained when severe or recurrent reactions

Geographic access modifies the threshold for prescribing a second auto-injector and the OIT eligibility discussion

Component-resolved diagnostics (Ara h 2 for peanut, Cor a 14 for hazelnut, Bos d 8 for milk casein) refine vs sensitisation-only and predict severity (EAACI 2025 PMID 39473345)

New dysphagia, food impaction, or persistent GI symptoms during OIT raise concern for eosinophilic esophagitis — a class effect of OIT (EAACI 2025 PMID 39473345)

Pregnancy does not preclude continuation of epinephrine auto-injector or established omalizumab; defer initiation of new OIT during pregnancy

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (6)

6 need judgement
  • informationallife_threateningfood_triggered_systemic_anaphylaxis_in_progress
    Active reaction with two-organ system involvement OR cardiovascular compromise OR airway compromise
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateoit_eosinophilic_esophagitis
    New dysphagia, food impaction, persistent retrosternal pain on a patient receiving peanut OIT
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateuncontrolled_asthma_prohibits_oit
    Asthma control inadequate (frequent SABA use, recent exacerbation, FEV1 reduced) in OIT-considered patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderateelevated_baseline_tryptase_or_recurrent_unexplained_anaphylaxis
    Baseline tryptase >=11.4 ng/mL OR recurrent unexplained anaphylaxis OR sting-related anaphylaxis with food-allergy overlap
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatealpha_gal_delayed_meat_anaphylaxis
    Delayed 3-6h post-mammalian-meat systemic reaction with Lone Star tick exposure
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmildhigh_risk_infant_leap_window
    High-risk infant 4-11 mo (severe eczema and/or egg allergy) within early-peanut-introduction window
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

This dossier does not reference any calculators.

Recommended regimen

IgE-mediated food allergy — avoidance + emergency action plan + immunomodulatory disease-modifying therapy (EAACI 2025)
axis: ige_food_allergy_avoidance_action_plan_and_immunomodulationstep 1 - Step 1 — Avoidance + emergency action plan + auto-injector (every patient, lifelong)
Selected step "Step 1 — Avoidance + emergency action plan + auto-injector (every patient, lifelong)" — All confirmed IgE-FA patients, all severities — the non-negotiable substrate
  • strict_allergen_avoidance_and_label_reading
    first line
    avoidance
    EAACI 2025 (PMID 39473345) — confirmed IgE-FA mandates strict avoidance with dietitian-supported nutritional adequacy and label-reading education.
  • written_emergency_action_plan
    first line
    patient_education
    EAACI 2025 (PMID 39473345) — every patient receives a written action plan documenting trigger, recognition, when to use epinephrine, and when to call emergency services.
  • epinephrine
    rescue
    alpha_beta_adrenergic_agonist_auto_injector
    0.15 mg IM (7.5-25 kg) / 0.3 mg IM (>=25 kg) • IM lateral thigh • PRN for systemic reaction; may repeat in 5-15 min (max: Per device; two devices carried)
    triggers: systemic_reaction, airway_or_circulatory_involvement
    EAACI 2025 (PMID 39473345) — IM epinephrine is the first-line rescue for anaphylaxis; at-risk patients carry two auto-injectors. Technique re-taught at every visit.
    rxcui 3992

outpatient playbook — drug actions (4)

  1. 1. epinephrine auto-injector x 2 + written action plan
    rxcui 3992
    0.15 mg or 0.3 mg IM (weight-based) • IM • PRN for systemic reaction; may repeat 5-15 min
    trigger: Confirmed IgE-FA — every patient (EAACI 2025 PMID 39473345)
    Rescue mainstay; two devices for at-risk; technique re-taught at every visit
  2. 2. cetirizine for mild cutaneous-only reactions
    rxcui 20610
    10 mg • PO • once daily PRN
    trigger: Isolated mild cutaneous response (EAACI 2025 PMID 39473345)
    H1 adjunct — never a substitute for epinephrine in systemic reactions
  3. 3. peanut OIT (Palforzia) for eligible 1-17 y
    rxcui 2279411
    300 mg maintenance after uptitration • PO • daily lifelong
    trigger: Peanut-allergic 1-17 y, asthma controlled, OIT centre available (EAACI 2025 PMID 39473345; PALISADE PMID 30449234)
    Desensitisation to ~600 mg in 67% on AR101 vs 4% placebo at 1 y
  4. 4. omalizumab for IgE-FA >=1 y, multi-food or OIT-intolerant
    rxcui 302379
    Weight+IgE-banded label dose • SC • q2-4wk
    trigger: IgE-FA age >=1 y, multi-food or OIT impractical (EAACI 2025 PMID 39473345; OUtMATCH PMID 38407394)
    Anti-IgE — 67% tolerated >=600 mg peanut + >=1 g of 2 other foods at 16-20 wk vs 7% placebo

Auto-drafted A&P note

outpatient

Subjective

- Possible entry pathways: Reproducible food-triggered urticaria/angioedema/wheeze/GI/anaphylaxis within minutes-2h of ingestion (EAACI 2025 PMID 39473345); Positive food-specific IgE or skin-prick test in the setting of a compatible history (EAACI 2025 PMID 39473345); Prior food-triggered anaphylaxis requiring epinephrine — referred from allergy.anaphylaxis.v1 for chronic disease management.

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**IgE-mediated food allergy** (allergy.food-allergy.core.v1).
Phenotype framing: Terminal differential: IgE-FA (this engine) vs non-IgE FA (FPIES, EoE, proctocolitis — different pathophysiology, no sIgE) vs oral allergy syndrome / pollen-food allergy syndrome (Bet v 1-related, raw fruit, mild oropharyngeal) vs scombroid (histamine in spoiled fish, not allergy) vs alpha-gal syndrome (delayed 3-6h post mammalian meat, tick-mediated) vs food intolerance (e.g., lactose, fructose — non-immune).
Scope: Frame as a CHRONIC IgE-mediated reactivity managed through avoidance + emergency action plan + auto-injector, with optional disease-modifying immunomodulatory therapy (peanut OIT, omalizumab) per EAACI 2025. Acute reactions route to allergy.anaphylaxis.v1.

No severity triggers fired against current inputs.

Plan

Regimen axis: **IgE-mediated food allergy — avoidance + emergency action plan + immunomodulatory disease-modifying therapy (EAACI 2025)** — step "Step 1 — Avoidance + emergency action plan + auto-injector (every patient, lifelong)".
1. strict_allergen_avoidance_and_label_reading (avoidance, first line) — EAACI 2025 (PMID 39473345) — confirmed IgE-FA mandates strict avoidance with dietitian-supported nutritional adequacy and label-reading education.
2. written_emergency_action_plan (patient_education, first line) — EAACI 2025 (PMID 39473345) — every patient receives a written action plan documenting trigger, recognition, when to use epinephrine, and when to call emergency services.
3. epinephrine 0.15 mg IM (7.5-25 kg) / 0.3 mg IM (>=25 kg) IM lateral thigh PRN for systemic reaction; may repeat in 5-15 min (alpha_beta_adrenergic_agonist_auto_injector, rescue) — EAACI 2025 (PMID 39473345) — IM epinephrine is the first-line rescue for anaphylaxis; at-risk patients carry two auto-injectors. Technique re-taught at every visit.

Setting playbook (outpatient) — Confirm IgE-FA diagnosis with history + targeted sIgE/SPT (OFC if uncertain), establish strict avoidance + written emergency action plan + epinephrine auto-injector, and offer shared-decision-making disease-modifying immunomodulation (peanut OIT, omalizumab) where eligible (EAACI 2025 PMID 39473345).
4. epinephrine auto-injector x 2 + written action plan 0.15 mg or 0.3 mg IM (weight-based) IM PRN for systemic reaction; may repeat 5-15 min — Confirmed IgE-FA — every patient (EAACI 2025 PMID 39473345) (Rescue mainstay; two devices for at-risk; technique re-taught at every visit)
5. cetirizine for mild cutaneous-only reactions 10 mg PO once daily PRN — Isolated mild cutaneous response (EAACI 2025 PMID 39473345) (H1 adjunct — never a substitute for epinephrine in systemic reactions)
6. peanut OIT (Palforzia) for eligible 1-17 y 300 mg maintenance after uptitration PO daily lifelong — Peanut-allergic 1-17 y, asthma controlled, OIT centre available (EAACI 2025 PMID 39473345; PALISADE PMID 30449234) (Desensitisation to ~600 mg in 67% on AR101 vs 4% placebo at 1 y)
7. omalizumab for IgE-FA >=1 y, multi-food or OIT-intolerant Weight+IgE-banded label dose SC q2-4wk — IgE-FA age >=1 y, multi-food or OIT impractical (EAACI 2025 PMID 39473345; OUtMATCH PMID 38407394) (Anti-IgE — 67% tolerated >=600 mg peanut + >=1 g of 2 other foods at 16-20 wk vs 7% placebo)

Non-pharmacologic actions:
- Dietitian referral for nutritional adequacy + label-reading (EAACI 2025 PMID 39473345)
- Written emergency action plan + auto-injector technique demonstration at every visit (EAACI 2025 PMID 39473345)
- School/workplace plan + medical-alert identification (EAACI 2025 PMID 39473345)
- Clinical-psych referral for significant FA-related anxiety / coping burden (EAACI 2025 PMID 39473345)
- LEAP-based early peanut introduction counselling for high-risk infants 4-11 mo (LEAP PMID 25705822)

AVOID / contraindication checks:
- Uncontrolled asthma relative contraindication to oit (EAACI 2025 PMID 39473345 — achieve control before initiating peanut OIT)
- Oit causes on treatment reactions including anaphylaxis (Palforzia label; PALISADE PMID 30449234 — keep epinephrine accessible; daily dose timing + cofactor avoidance)
- Oit class effect eosinophilic esophagitis (EAACI 2025 PMID 39473345 — dysphagia/food impaction during OIT triggers endoscopy)
- Omalizumab rare anaphylaxis (FDA label — observation window post injection; maintain epinephrine access)
- Antihistamines and corticosteroids are not substitutes for epinephrine in systemic reactions (EAACI 2025 PMID 39473345)
- Pregnancy defer new oit initiation (EAACI 2025 PMID 39473345 — continue established therapy after individualised review)
- Beta blockers may attenuate epinephrine response (use lowest effective dose; counsel patient on rescue plan)

Monitoring

Regimen monitoring:
- auto injector carry expiry technique at every visit (EAACI 2025 PMID 39473345)
- annual sige or component testing for milk egg wheat for natural tolerance (EAACI 2025 PMID 39473345)
- oit daily dose diary plus eosinophilic esophagitis symptom screen (EAACI 2025 PMID 39473345; Palforzia label)
- asthma control at each oit visit required to continue (EAACI 2025 PMID 39473345)
- omalizumab injection site and post injection observation (FDA label)
- dietitian annual review for growth and nutrient adequacy pediatric (EAACI 2025 PMID 39473345)

Setting (outpatient) monitoring:
- Annual sIgE / component testing for milk/egg/wheat (natural-tolerance check) (EAACI 2025 PMID 39473345)
- Auto-injector carry/expiry/technique at every visit
- OIT-on-treatment: daily dose diary, EoE symptom screen, asthma control

Follow-up plan: Lifelong chronic-allergy maintenance: written action plan + auto-injector + label-reading habit + school/workplace plan + medical-alert identification. School staff training in epinephrine administration. Re-evaluation for natural tolerance (milk/egg/wheat childhood allergies) via supervised OFC at allergist discretion. Lifelong avoidance counselling for peanut/tree-nut/sesame/shellfish (low natural-tolerance rate).
- Close-out criterion: Action plan reviewed; school/workplace plan in place; tolerance re-evaluation scheduled where indicated

Monitoring phase: Auto-injector expiry + carry + technique at every visit. Dietitian re-review annually (especially milk/egg/wheat allergies for growth + nutrient adequacy). Annual sIgE / component testing for evidence of natural tolerance (especially milk/egg/wheat — frequent in childhood). OIT-on-treatment surveillance: daily dosing adherence, dose-reaction-and-cofactor diary, EoE symptom screen, asthma control. Omalizumab: q2-4wk SC; injection-site + rare anaphylaxis-to-omalizumab counselling.

Disposition

Current setting: outpatient — Confirm IgE-FA diagnosis with history + targeted sIgE/SPT (OFC if uncertain), establish strict avoidance + written emergency action plan + epinephrine auto-injector, and offer shared-decision-making disease-modifying immunomodulation (peanut OIT, omalizumab) where eligible (EAACI 2025 PMID 39473345).

Disposition criteria:
- Continue outpatient allergy follow-up with annual review + as-needed during therapy uptitration
- OIT initiation/uptitration sessions require OIT-capable centre with rescue epinephrine
- ED transfer for active anaphylaxis only

Escalation triggers (move to higher acuity):
- Systemic reaction in progress (two-organ system / cardiovascular / airway) → route to allergy.anaphylaxis.v1 for IM epinephrine + supportive care
- New dysphagia / food impaction during OIT → endoscopy for EoE (OIT class effect)
- Baseline tryptase >=11.4 ng/mL or recurrent unexplained anaphylaxis → mast-cell disorder workup (route allergy.mast-cell-activation-syndrome.core.v1)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] Active reaction with two-organ system involvement OR cardiovascular compromise OR airway compromise
- [MODERATE] New dysphagia, food impaction, persistent retrosternal pain on a patient receiving peanut OIT
- [MODERATE] Asthma control inadequate (frequent SABA use, recent exacerbation, FEV1 reduced) in OIT-considered patient

Citations

- EAACI 2025 IgE-mediated food allergy guideline (Santos et al, Allergy 2024-10; PMID 39473345); LEAP NEJM 2015 (Du Toit; PMID 25705822); PALISADE NEJM 2018 (PMID 30449234); OUtMATCH NEJM 2024 (Wood; PMID 38407394); EPITOPE phase 3 extension 2025 (PMID 40204253; PMID 39956162) [PMID:39473345](https://pubmed.ncbi.nlm.nih.gov/39473345/)
- Cited evidence (PMID 25705822) [PMID:25705822](https://pubmed.ncbi.nlm.nih.gov/25705822/)
- Cited evidence (PMID 30449234) [PMID:30449234](https://pubmed.ncbi.nlm.nih.gov/30449234/)
- Cited evidence (PMID 38407394) [PMID:38407394](https://pubmed.ncbi.nlm.nih.gov/38407394/)
- Cited evidence (PMID 40204253) [PMID:40204253](https://pubmed.ncbi.nlm.nih.gov/40204253/)

Last reconciled with current guidelines: 2026-05-26.
References
  • EAACI 2025 IgE-mediated food allergy guideline (Santos et al, Allergy 2024-10; PMID 39473345); LEAP NEJM 2015 (Du Toit; PMID 25705822); PALISADE NEJM 2018 (PMID 30449234); OUtMATCH NEJM 2024 (Wood; PMID 38407394); EPITOPE phase 3 extension 2025 (PMID 40204253; PMID 39956162) — PMID:39473345
  • Cited evidence (PMID 25705822) — PMID:25705822
  • Cited evidence (PMID 30449234) — PMID:30449234
  • Cited evidence (PMID 38407394) — PMID:38407394
  • Cited evidence (PMID 40204253) — PMID:40204253