Food Allergy Prevention and Treatment Advances, With Manish Ramesh, MD, PhD

In an interview with HCPLive, Manish Ramesh, MD, PhD, chief of the division of allergy & immunology at Albert Einstein College of Medicine, cited early allergen introduction, oral immunotherapy (OIT), and omalizumab (Xolair) as key advances in food allergy prevention and treatment.

Ramesh described food allergy as the first chronic immune illness clinicians can prevent, not only treat. He linked the first population-level reduction in peanut allergy incidence to the early introduction strategy, identified roughly 10 years ago.¹^,2

“You can’t prevent lupus, you can’t prevent asthma, but you can prevent food allergies,” Ramesh said. “Early introduction of foods in very young children can help prevent the development of food allergies in the future.”

Early Allergen Introduction and Declining Peanut Allergy Incidence

Primary care data from a multistate pediatric network support the population-level shift Ramesh described. Stanislaw J. Gabryszewski and colleagues compared health records of children aged 0 to 3 years before and after the 2015 early peanut introduction guidelines and 2017 addendum guidelines.¹

The cumulative incidence of peanut IgE-mediated food allergy fell from 0.79% to 0.53% after the initial guidelines (hazard ratio [HR], 0.65; 95% CI, 0.55-0.77; P <.0001).¹ Following the addendum guidelines, incidence fell further to 0.45% (HR, 0.55; 95% CI, 0.46-0.66; P <.0001).¹ Rates of any IgE-mediated food allergy also declined, from 1.46% to 1.02% (HR, 0.69; 95% CI, 0.61-0.78).¹

Ramesh said the timing of exposure matters beyond foods alone. Early childhood exposures, including environmental exposures, appear central to whether allergic disease develops, he noted.

Oral Immunotherapy and Omalizumab for Food Allergy

Oral immunotherapy (OIT) remains the most common treatment option, according to Ramesh.

Ramesh also highlighted omalizumab as the first biologic approved for food allergy in both children and adults.³ He said the anti-IgE antibody reduces reaction severity and raises the amount of food needed to trigger a reaction.

Among 177 children and adolescents aged 1 to 17 years in a randomized, placebo-controlled trial, 67% receiving omalizumab tolerated a single dose of ≥ 600 mg of peanut protein without dose-limiting symptoms.⁴ This compared with 7% of participants receiving placebo (P <.001). Results for cashew (41% vs 3%), milk (66% vs 10%), and egg (67% vs 0%) were consistent with the primary end point, and safety end points did not differ between groups aside from more injection-site reactions with omalizumab.

Sublingual and epicutaneous immunotherapy remain in development.^5,6 Ramesh said both are expected to become available for clinical use soon.

How Genetics Is Reshaping Allergic Disease Phenotyping

Asked how understanding of allergic disease has changed in the past decade, Ramesh pointed first to immune mechanisms. Recognition of distinct phenotypes in asthma, chronic urticaria, and atopic dermatitis has shifted management toward immune mechanism-based phenotyping, he said.

Ramesh also cited hereditary alpha-tryptasemia, defined by extra copies of the tryptase gene, as a readily screened genetic trait associated with increased anaphylaxis risk.⁷ Epigenetic changes, which are heritable but arise far faster than mutations, account for much of the generation-to-generation rise in atopy, according to Ramesh.

Monogenic disorders have offered further insight, as genetic testing has revealed single-gene mutations in some patients presenting with severe allergic disease and immune dysfunction. Unlike classic immunodeficiencies, where a mutation confers susceptibility to infection, these mutations alter immune behavior itself.

“In this case, the alterations in the genes change how your immune system behaves and, in some ways increases allergic disease, similar to what we would see with autoimmune disease,” said Ramesh.

Ramesh said these insights into immune mechanisms are now driving development of new biologics and small molecules for chronic allergic disease. He noted these agents already support management of properly phenotyped patients with asthma, atopic dermatitis, and chronic urticaria.

References

1. Gabryszewski SJ, Dudley J, Faerber JA, et al. Guidelines for early food introduction and patterns of food allergy. Pediatrics. 2025;156(5). doi:10.1542/peds.2024-070516

2. Gabryszewski S, Gupta R, Hernandez-Trujillo V, et al. Peanut Allergy Rates Plummet 10 Years After AAP Early Introduction Guidelines. HCPLive. Published October 30, 2025. Accessed October 14, 2026. https://www.hcplive.com/view/peanut-allergy-rates-plummet-10-years-aap-early-introduction-guidelines

3. Smith T. FDA Approves Omalizumab as First Treatment of 1 or More Food Allergies for Children, Adults. HCPLive. Published February 16, 2024. Accessed October 14, 2026. https://www.hcplive.com/view/fda-approves-omalozumab-first-treatment-of-1-or-more-food-allergies-for-children-adults

4. Wood RA, Togias A, Sicherer SH, et al. Omalizumab for the treatment of multiple food allergies. N Engl J Med. 2024;390(10):889-899. doi:10.1056/NEJMoa2312382

5. Larenas-Linnemann D. Sublingual Immunotherapy for Allergy in 2026, With Désirée Larenas-Linnemann, MD. HCPLive. Published March 9, 2026. Accessed October 14, 2026. https://www.hcplive.com/view/sublingual-immunotherapy-allergy-2026-d-sir-e-larenas-linnemann-md

6. Derman C. Viaskin Peanut Patch FAQ: Where It Fits Beside Omalizumab and OIT. HCPLive. Published October 8, 2026. Accessed October 14, 2026. https://www.hcplive.com/view/viaskin-peanut-patch-faq-omalizumab-oit

7. Korošec P, Lyons JJ, Svetina M, et al. Hereditary α-tryptasemia is Associated With Anaphylaxis to Antibiotics and Monoclonal Antibodies. J Allergy Clin Immunol Pract. 2025;13(6):1449-1456.e4. doi:10.1016/j.jaip.2025.04.013