La Rochelle P (2017). Using randomized, double-blind, n-of-1 trials of food challenge to diagnose food allergy and assess the effectiveness of food allergen avoidance.

© Pierre La Rochelle, Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada G0R 1Z0 Email: pierre.la.rochelle@videotron.ca.


Cite as: La Rochelle P (2017). Using randomized, double-blind, n-of-1 trials of food challenge to diagnose food allergy and assess the effectiveness of food allergen avoidance. JLL Bulletin: Commentaries on the history of treatment evaluation (http://www.jameslindlibrary.org/articles/using-randomized-double-blind-n-1-trials-food-challenge-diagnose-food-allergy-assess-effectiveness-food-allergen-avoidance/)


Food allergy leading to acute distress can result in chronic feelings of apprehension about recurrences. As the outcomes of food allergy include death, caution must prevail. The impact on the life of each person suspected of having a food allergy and those close to them can be substantial, so progress in valid identification of food allergy is very important. Specialists in allergies have been aware of these issues since the middle of the 20th century, and have gradually developed stepwise experimental approaches through which alleged food allergies can be identified objectively and safely.

In 1950, Mary Loveless pioneered an improved method of establishing the existence of food allergy rigorously using placebos to blind both patients and clinicians.

Every attempt was made to prevent the subject from learning on which occasion milk was involved. The placebo consisted of one of three commercial antacids, Amphojel, Basaljel, or Titralac (see footnotes, Table II), mixed with water on one occasion and with milk on another. The consumer was asked to close his eyes and his nostrils until after the meal had been brought into the room and swallowed. An independent technician decided which feeding was to include milk and prepared both meals in an adjacent room without informing the patient or the physician of their identity (Loveless 1950).

In a series of 8 patients with alleged milk allergy, two failed to demonstrate any symptom during the test. This new diagnostic technique provided evidence to assess whether symptoms actually resulted from food allergy.

Twenty-one years passed before Maslansky and Wein (1971) used Mary Loveless’s experimental design to compare chocolate with a placebo to investigate alleged allergy to the former, chosen for its high prevalence and relative safety.

Two sets of opaque capsules were prepared for us, one containing pure de-fatted cocoa with all but 2% cocoa than is found in 2 average ¾ ounce bars of packaged milk chocolate. The second capsules, which appeared identical to the first, contained an inert placebo.

Using a double-blind procedure, ½ the cases were started on Code 1 and the other ½ on Code 2. They took 6 capsules every morning after breakfast for 6 consecutive days…

After 2 day period, patients were interviewed, and the alternate capsules were supplied for an additional 6-day trial, …(Maslansky and Wein 1971)

Of 8 cases of alleged chocolate allergy, symptoms were provoked in only 3, none with placebo. Furthermore, of the 3 who tested positive in these blinded challenges, only one tested positive to the skin scratch test. The disparity between clinical symptoms, skin test results and the results of the placebo controlled food challenge raised questions about the validity of then current approaches to diagnosing allergies.

Five years later, Charles May applied the same diagnostic technique in 38 children with a variety of food allergies, including allergy to peanuts and eggs. Symptoms were provoked in only 11 of the 38 children (May 1976).

Despite a few false-negative results (Caffarelli and Petroccione 2001), the double-blind placebo controlled food challenge became a gold standard for diagnosing food allergies in clinical research and occasionally in clinical practice (Lieberman and Sicherer 2011).

In 2015, the diagnostic technique contributed to a paradigm shift in food allergy prevention (Du Toit, Roberts et al. 2015). For over a decade, alleged peanut allergy appeared to have been on the increase. Du Toit et al, selected infants judged to be at risk of peanut allergy and allocated them at random either to avoidance of peanuts, as the then current guidelines recommended, or to sustained exposure to peanuts. The study showed a clear advantage for the peanut consumption group: only 1.9 per cent of them had developed allergy by 60 months of age compared to 19.7 per cent of those allocated to the avoidance group (p<0.001).

The double-blind placebo controlled food challenge trial design shares many similarities with n-of-1 trials (Mirza et al. 2017). Both address individual response. The former is typically used to diagnose or to document harms or the absence of harms, using escalating doses with typically one cycle of comparison. N-of-1 trials, by contrast, are typically used to assess possible benefits, often using many cycles, with or without washout periods. As an acknowledgement of the important contribution of N-of-1 trials to the development of evidence they were placed at the top of the evidence hierarchy in 2000 (Guyatt et al. 2000).

At the time of writing, a 3-year-old boy died during an oral food challenge, the unblinded version of the double blind placebo controlled food challenge (DBPCFC), the preferred test when the presenting symptoms are deemed to be objective. In their initial response to this tragedy, the learned societies have urged revision of protocols and settings but have emphasized the need to retain these important diagnostic tools (American Academy and College of Allergy, Asthma & Immunology, and Canadian College of Allergy, Asthma & Immunology 2017).

The introduction of double-blind placebo controlled food challenges has contributed importantly to understanding and managing food allergies. Viewed more widely, this trial design can be seen as a vehicle for delivering more personalised medicine.

This James Lind Library article has been republished in the Journal of the Royal Society of Medicine 2018;111:31-32. Print PDF

References

American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma & Immunology and Canadian Society of Allergy and Clinical Immunology (2017). Statement to public regarding OFC fatality.

Caffarelli C, Petroccione T (2001). False-negative food challenges in children with suspected food allergy. Lancet 358:1871-1872.

Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, Brough HA, Phippard D, Basting M, Feeney M, Turcanu V, Sever ML, Gomez Lorenzo M, Plaut M, Lack G, for the LEAP Study Team. (2015). Randomized trial of peanut consumption in infants at risk for peanut allergy. N Engl J Med 372:803-813.

Guyatt G, Haynes RB, Jaeschke RZ, Cook DJ, Naylor CD, Wilson MC, Richardson WS (2000). Users; guide to the medical literature: XXV. Evidence-based medicine: principles for applying the users’ guides to patient care. Evidence-Based Medicine Working Group. JAMA 284:1290-96.

Lieberman JA, Sicherer SH (2011). Diagnosis of food allergy: epicutaneous skin tests, in vitro tests, and oral food challenge. Curr Allergy Asthma Rep 11: 58-64.

Loveless MH (1950). Milk allergy: a survey of its incidence; experiments with a masked ingestion test. J Allergy 21:489-499.

Maslansky L, Wein G (1971). Chocolate allergy: a double-blind study. Conn Med 35:5-9.

May CD (1976). Objective clinical and laboratory studies of immediate hypersensitivity reactions to foods in asthmatic children. J Allergy Clin Immunol 58: 500-515.