Near-fatal and fatal anaphylaxis induced by food is a critical event for the patient/caregivers but is also a challenge for the physician/allergist for both acute and long-term care. We aimed to describe the epidemiology of food-induced near-fatal anaphylaxis (NFA), the key factors that may impact their approach, and its management.

In this narrative review, we have focused on food-induced NFA moving from epidemiological data and risk factors to management using a search of PubMed online databank.

NFA is not well-defined in the literature. Food-induced anaphylaxis mortality rate is estimated less than 0.3 deaths per million persons-years in the general population. Refractory anaphylaxis also appears to be rare (< 2 % of anaphylaxis cases). Food-induced NFA are mostly observed in children but can also occur in adults, even the elderly. While most countries report peanut/tree nuts being frequently involved in NFA, seafood or milks are reported in other countries.

Prior anaphylaxis, asthma diagnosis, IgE sensitization or basophil activation tests are not good predictors of NFA whereas adolescence/young adulthood are associated with a higher risk of severe outcome. However there remain major knowledge gaps regarding risk factors of NFA, including the impact of asthma.

There is a clear room for improvement in the prevention and management of NFA to focus on: prompt adrenaline use in prehospital care, innovations regarding alternative forms of injectable adrenaline, prevention at school, therapeutic education, food allergen avoidance and adequate labelling. Some patients may benefit from immunotherapy and/or biologicals in the context of personalized care.

A collaborative research is needed to address knowledge gaps in anaphylaxis, even more for food-induced NFA. We need to go further in identifying biomarkers, pathophysiologic pathways, genetic factors that may be associated with an increased risk of NFA. Novel therapeutic options should be envisaged in these patients.