This Week in Allergy & Immunology — Oct 25, 2026
Generated Oct 26, 2026 · 10:10
The week's practice-changing Allergy & Immunology research, summarized for clinicians.
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Rituximab vs Azathioprine for Eosinophilic Granulomatosis With Polyangiitis Maintenance Therapy: A Randomized Clinical Trial.
In 98 patients with eosinophilic granulomatosis with polyangiitis, rituximab was not superior to azathioprine for maintaining remission and roughly doubled severe infections, largely from COVID-19.
JAMA · 2026 · PubMed
This week’s papers
- 01
Comparative efficacy and safety of treatments for eosinophilic esophagitis: Systematic review and network meta-analysis of randomized controlled trials.
Across 48 randomized trials in eosinophilic esophagitis, high-frequency dupilumab and swallowed topical corticosteroids ranked among the most effective for symptoms and quality of life, while elimination diet benefits were modest.
Roldan Y et al. · Journal of Allergy and Clinical Immunology · 2026
From the briefingIn the Journal of Allergy and Clinical Immunology, Roldan and colleagues report a systematic review and network meta-analysis of 48 randomized trials, including nearly four thousand children and adults with eosinophilic esophagitis [1]. High-frequency dupilumab and swallowed topical corticosteroids came out among the most effective therapies for both symptoms and quality of life, with high certainty for dupilumab on symptoms and moderate certainty for steroids. Certain other biologics and epicutaneous immunotherapy were likely no different from placebo for symptoms. Many interventions lowered peak eosinophil counts, and the authors stress that histologic improvement does not guarantee that patients feel better. Four- and six-food elimination diets may beat one-food elimination for symptoms, but only with low certainty and a heavier burden. For practice, this is the most comprehensive comparative evidence yet that steroids and dupilumab sit at the top tier, while the case for extensive elimination diets looks modest.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 02
Total IgE Levels Better Predict Atopic Dermatitis Flares Than Disease Severity, and Both Are Reduced by Dupilumab Treatment.
In adults with moderate-to-severe atopic dermatitis on topical steroids, higher baseline total IgE predicted flares better than disease severity, and dupilumab lowered IgE and abolished this association.
Kim BS et al. · The Journal of Allergy and Clinical Immunology: In Practice · 2026
From the briefingTurning to the skin, Kim and colleagues in the Journal of Allergy and Clinical Immunology: In Practice reanalysed the CHRONOS trial of adults with moderate-to-severe atopic dermatitis [2]. Among patients on topical steroids alone, higher baseline total IgE raised the odds of a flare by roughly sixty percent, while baseline disease severity showed no clear link to flares. The IgE signal was concentrated in severe disease. In dupilumab-treated patients, IgE fell substantially and the association with flares disappeared. This is a post hoc analysis, so it raises total IgE as a candidate flare marker rather than establishing it as a decision tool.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 03
Personalised dupilumab therapy in severe asthma: real-world dosing interval prolongation among early responders.
Among 24 early dupilumab responders with severe asthma, extending dosing to a median of every four weeks maintained lung function, symptom control and zero exacerbations in a small uncontrolled cohort.
Greig R et al. · The Journal of Allergy and Clinical Immunology: In Practice · 2026
From the briefingGreig and colleagues took 24 early responders to dupilumab and extended the dosing interval, to a median of every four weeks, with a range of two to six [3]. Lung function, exhaled nitric oxide, eosinophils and symptom control all improved from baseline on standard dosing and then held steady after prolongation, with no exacerbations in either treated period. The authors point to cost and convenience, but this is a small, uncontrolled cohort of selected responders, so it is hypothesis-generating rather than a basis for a new dosing standard.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 04
Mepolizumab reduces oral corticosteroid use across distinct severe asthma phenotypes: 2-year REALITI-A study.
In 822 real-world severe asthma patients, mepolizumab cut median oral steroid doses by 70 to 100 percent over two years regardless of eosinophils, IgE, atopy or FeNO.
Chaudhuri R et al. · The Journal of Allergy and Clinical Immunology: In Practice · 2026
From the briefingChaudhuri and colleagues offer a post hoc look at the two-year REALITI-A observational study of 822 adults starting mepolizumab [4]. Median oral steroid dose reductions ranged from 70 to 100 percent across every subgroup examined, and somewhere between roughly two fifths and seven tenths of patients in each subgroup had stopped maintenance steroids altogether, regardless of omalizumab eligibility, eosinophil count, IgE level, atopic status or nitric oxide. That breadth is notable, though the observational, uncontrolled design means it cannot match the certainty of randomized data.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 05
Rituximab vs Azathioprine for Eosinophilic Granulomatosis With Polyangiitis Maintenance Therapy: A Randomized Clinical Trial.
In 98 patients with eosinophilic granulomatosis with polyangiitis, rituximab was not superior to azathioprine for maintaining remission and roughly doubled severe infections, largely from COVID-19.
Puéchal X et al. · JAMA · 2026
From the briefingThe eosinophilic theme extends to vasculitis with the week's most rigorous trial. In JAMA, Puéchal and colleagues ran a double-blind, double-dummy trial in 98 French patients with eosinophilic granulomatosis with polyangiitis who had recently reached remission, comparing rituximab every six months with daily azathioprine for maintenance [5]. Rituximab was not superior: mean time in remission on low-dose prednisone was about 91 weeks with rituximab versus 96 weeks with azathioprine, a non-significant difference. Relapse rates and airway exacerbations were also similar. Meanwhile, severe infections were roughly twice as frequent with rituximab, about 47 percent versus 25 percent, largely driven by severe COVID-19 during the early pandemic. The trial is modest in size, but it removes any assumption that rituximab is the better maintenance agent in this disease.
If you only have time for one paper this week, make it the JAMA trial of rituximab versus azathioprine for maintenance in eosinophilic granulomatosis with polyangiitis [5]. It is a rare double-blind randomized trial in this disease, and it reopens the question of whether rituximab offers any maintenance advantage worth its higher infection burden.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 06
Cofactors in Anaphylaxis: Insights From the European Anaphylaxis Registry.
In nearly 17,000 registry anaphylaxis cases, about half involved suspected cofactors, with infection in children and alcohol in adults linked to severity and cofactors linked to delayed onset.
Worm M et al. · Clinical and Experimental Allergy · 2026
From the briefingFrom the European Anaphylaxis Registry, Worm and colleagues in Clinical and Experimental Allergy analysed nearly seventeen thousand reactions [6]. Close to half of cases had at least one suspected cofactor, far more often in adults than in children. Medication was the leading suspected cofactor in adults and exercise led in children. Severity tended to rise with the number of cofactors, with acute infection in children and alcohol in adults with food reactions showing the most consistent effects. Cofactors were also linked to a longer delay between exposure and symptom onset in food-induced reactions. Registry data cannot prove causation, but the authors argue that a delayed onset is a cue to look for cofactors.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 07
Cumulative 600-mg Aspirin Oral Provocation Testing in Skin-Predominant NSAID Hypersensitivity: A Retrospective Cohort Study.
In 122 adults with skin-predominant NSAID hypersensitivity, most positive aspirin challenges appeared only at the cumulative 600 mg dose, and nearly all reactions occurred within six hours.
Kim JH et al. · Annals of Allergy, Asthma & Immunology · 2026
From the briefingIn the Annals of Allergy, Asthma and Immunology, Kim and colleagues describe 122 adults with skin-predominant NSAID hypersensitivity undergoing aspirin challenge to a cumulative 600 milligrams [7]. Roughly seven in ten patients with suspected cross-reactive phenotypes reacted, rising to about nine in ten with NSAID-exacerbated cutaneous disease. Just over three quarters of the reactions appeared only after the final dose, and nearly all reactions occurred within six hours. Six patients received epinephrine and none needed emergency transfer. The single-centre retrospective design limits generalization, but the data suggest lower cumulative doses or shorter observation could miss many reactors.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 08
The Cost-Effectiveness of Requiring Universal and Indefinite Epinephrine Prescriptions for All Patients Receiving Omalizumab to Prevent Anaphylaxis Fatality.
A Markov simulation found that requiring indefinite community epinephrine prescriptions for every omalizumab patient is not cost-effective, arguing against a strong universal recommendation.
Shaker M et al. · The Journal of Allergy and Clinical Immunology: In Practice · 2026
From the briefingFinally, Shaker and colleagues in the Journal of Allergy and Clinical Immunology: In Practice modelled universal, indefinite epinephrine prescriptions for every patient on omalizumab and found the policy was not cost-effective [8]. The authors conclude that a strong blanket recommendation is not justified, which supports individualized rather than universal prescribing, though this rests on simulation rather than outcome data.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 09
A Link Between Immunoglobulin M Levels and Overwhelming Post-Splenectomy Infection Risk in a National Asplenia Cohort.
In nearly 3,000 people with asplenia, serum IgM below 61.5 mg/dL was strongly associated with overwhelming post-splenectomy infection, discriminating cases with about 87 percent sensitivity and 85 percent specificity.
Day WG et al. · The Journal of Allergy and Clinical Immunology: In Practice · 2026
From the briefingIn the Journal of Allergy and Clinical Immunology: In Practice, Day and colleagues studied about three thousand people with anatomic or functional asplenia, among whom 47 developed overwhelming post-splenectomy infection, overwhelmingly pneumococcal and usually despite documented vaccination [9]. Serum IgM below 61.5 milligrams per decilitre was found in nearly nine in ten patients with infection, compared with about one in seven patients without it, and low IgM discriminated the two groups well, with sensitivity and specificity both in the mid-eighties. Retrospective and with few events, this needs prospective validation, but it points to a simple test that might flag patients for closer surveillance.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
- 10
Long-term prophylaxis for hereditary angioedema: Navigating the switch between therapies.
With garadacimab and donidalorsen expanding hereditary angioedema prophylaxis options, switching is increasingly common, yet direct evidence comparing switching strategies to avoid breakthrough attacks remains limited.
Banerji A et al. · World Allergy Organization Journal · 2026
From the briefingIn the World Allergy Organization Journal, Banerji and colleagues review switching between long-term prophylactic therapies for hereditary angioedema, now that garadacimab and donidalorsen have joined C1 inhibitor, lanadelumab and berotralstat [10]. Switches happen for breakthrough attacks, side effects, family planning, treatment burden and cost, and differing mechanisms and clearance rates make transitions a real risk for gaps in protection. The authors are candid that direct evidence comparing switching strategies is limited.
Written by AI from the published abstract, for healthcare professionals. Not medical advice; check the paper before acting on it.
The full briefing
This AudioScholar briefing is generated by artificial intelligence for healthcare professionals and trainees. It is not medical advice.
Welcome to This Week in Allergy & Immunology. This week we're covering 10 notable papers spanning type 2 biologics across the airway, skin, gut and vasculature, anaphylaxis and drug provocation testing, and two rarer corners of the specialty, asplenia and hereditary angioedema. Let's dive in.
We start with the type 2 biologics, where this week's papers tackle comparative effectiveness, biomarkers, and how to use these drugs more efficiently. In the Journal of Allergy and Clinical Immunology, Roldan and colleagues report a systematic review and network meta-analysis of 48 randomized trials, including nearly four thousand children and adults with eosinophilic esophagitis [1]. High-frequency dupilumab and swallowed topical corticosteroids came out among the most effective therapies for both symptoms and quality of life, with high certainty for dupilumab on symptoms and moderate certainty for steroids. Certain other biologics and epicutaneous immunotherapy were likely no different from placebo for symptoms. Many interventions lowered peak eosinophil counts, and the authors stress that histologic improvement does not guarantee that patients feel better. Four- and six-food elimination diets may beat one-food elimination for symptoms, but only with low certainty and a heavier burden. For practice, this is the most comprehensive comparative evidence yet that steroids and dupilumab sit at the top tier, while the case for extensive elimination diets looks modest. Turning to the skin, Kim and colleagues in the Journal of Allergy and Clinical Immunology: In Practice reanalysed the CHRONOS trial of adults with moderate-to-severe atopic dermatitis [2]. Among patients on topical steroids alone, higher baseline total IgE raised the odds of a flare by roughly sixty percent, while baseline disease severity showed no clear link to flares. The IgE signal was concentrated in severe disease. In dupilumab-treated patients, IgE fell substantially and the association with flares disappeared. This is a post hoc analysis, so it raises total IgE as a candidate flare marker rather than establishing it as a decision tool.
Staying with biologics, two real-world asthma studies, both in the Journal of Allergy and Clinical Immunology: In Practice, look at doing more with less. Greig and colleagues took 24 early responders to dupilumab and extended the dosing interval, to a median of every four weeks, with a range of two to six [3]. Lung function, exhaled nitric oxide, eosinophils and symptom control all improved from baseline on standard dosing and then held steady after prolongation, with no exacerbations in either treated period. The authors point to cost and convenience, but this is a small, uncontrolled cohort of selected responders, so it is hypothesis-generating rather than a basis for a new dosing standard. Chaudhuri and colleagues offer a post hoc look at the two-year REALITI-A observational study of 822 adults starting mepolizumab [4]. Median oral steroid dose reductions ranged from 70 to 100 percent across every subgroup examined, and somewhere between roughly two fifths and seven tenths of patients in each subgroup had stopped maintenance steroids altogether, regardless of omalizumab eligibility, eosinophil count, IgE level, atopic status or nitric oxide. That breadth is notable, though the observational, uncontrolled design means it cannot match the certainty of randomized data.
The eosinophilic theme extends to vasculitis with the week's most rigorous trial. In JAMA, Puéchal and colleagues ran a double-blind, double-dummy trial in 98 French patients with eosinophilic granulomatosis with polyangiitis who had recently reached remission, comparing rituximab every six months with daily azathioprine for maintenance [5]. Rituximab was not superior: mean time in remission on low-dose prednisone was about 91 weeks with rituximab versus 96 weeks with azathioprine, a non-significant difference. Relapse rates and airway exacerbations were also similar. Meanwhile, severe infections were roughly twice as frequent with rituximab, about 47 percent versus 25 percent, largely driven by severe COVID-19 during the early pandemic. The trial is modest in size, but it removes any assumption that rituximab is the better maintenance agent in this disease.
Our second theme is anaphylaxis and provocation testing, where three papers refine how risk is assessed. From the European Anaphylaxis Registry, Worm and colleagues in Clinical and Experimental Allergy analysed nearly seventeen thousand reactions [6]. Close to half of cases had at least one suspected cofactor, far more often in adults than in children. Medication was the leading suspected cofactor in adults and exercise led in children. Severity tended to rise with the number of cofactors, with acute infection in children and alcohol in adults with food reactions showing the most consistent effects. Cofactors were also linked to a longer delay between exposure and symptom onset in food-induced reactions. Registry data cannot prove causation, but the authors argue that a delayed onset is a cue to look for cofactors. In the Annals of Allergy, Asthma and Immunology, Kim and colleagues describe 122 adults with skin-predominant NSAID hypersensitivity undergoing aspirin challenge to a cumulative 600 milligrams [7]. Roughly seven in ten patients with suspected cross-reactive phenotypes reacted, rising to about nine in ten with NSAID-exacerbated cutaneous disease. Just over three quarters of the reactions appeared only after the final dose, and nearly all reactions occurred within six hours. Six patients received epinephrine and none needed emergency transfer. The single-centre retrospective design limits generalization, but the data suggest lower cumulative doses or shorter observation could miss many reactors. Finally, Shaker and colleagues in the Journal of Allergy and Clinical Immunology: In Practice modelled universal, indefinite epinephrine prescriptions for every patient on omalizumab and found the policy was not cost-effective [8]. The authors conclude that a strong blanket recommendation is not justified, which supports individualized rather than universal prescribing, though this rests on simulation rather than outcome data.
Our last theme covers rarer conditions where immunologists are often the consultants of record. In the Journal of Allergy and Clinical Immunology: In Practice, Day and colleagues studied about three thousand people with anatomic or functional asplenia, among whom 47 developed overwhelming post-splenectomy infection, overwhelmingly pneumococcal and usually despite documented vaccination [9]. Serum IgM below 61.5 milligrams per decilitre was found in nearly nine in ten patients with infection, compared with about one in seven patients without it, and low IgM discriminated the two groups well, with sensitivity and specificity both in the mid-eighties. Retrospective and with few events, this needs prospective validation, but it points to a simple test that might flag patients for closer surveillance. In the World Allergy Organization Journal, Banerji and colleagues review switching between long-term prophylactic therapies for hereditary angioedema, now that garadacimab and donidalorsen have joined C1 inhibitor, lanadelumab and berotralstat [10]. Switches happen for breakthrough attacks, side effects, family planning, treatment burden and cost, and differing mechanisms and clearance rates make transitions a real risk for gaps in protection. The authors are candid that direct evidence comparing switching strategies is limited.
If you only have time for one paper this week, make it the JAMA trial of rituximab versus azathioprine for maintenance in eosinophilic granulomatosis with polyangiitis [5]. It is a rare double-blind randomized trial in this disease, and it reopens the question of whether rituximab offers any maintenance advantage worth its higher infection burden.
Here is what this week's evidence adds up to in Allergy & Immunology. First, for eosinophilic esophagitis, network meta-analysis now places high-frequency dupilumab and topical steroids at the top on outcomes patients feel, with elimination diets offering modest, low-certainty benefit. Second, in eosinophilic vasculitis, rituximab was not superior to azathioprine for maintaining remission and carried more severe infections, though the trial was small and conducted partly during the pandemic. Third, real-world asthma data suggest broad steroid-sparing with mepolizumab and possible dose spacing with dupilumab, but both come from observational or uncontrolled designs. Fourth, cofactors, delayed onset and prolonged observation all matter in anaphylaxis and aspirin challenge, based on registry and single-centre data. And finally, low IgM emerges as a promising but unvalidated marker of fatal infection risk in asplenia.
That's your roundup for This Week in Allergy & Immunology. The full transcript and references are available on the episode page. This is an AI-curated summary — for clinical decisions, always consult primary sources and current guidelines. See you next week.
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