Cashew oral immunotherapy for desensitizing cashew-pistachio allergy (NUT CRACKER study)

Arnon Elizur*, Michael Y. Appel, Liat Nachshon, Michael B. Levy, Naama Epstein-Rigbi, Yael Koren, Marie Holmqvist, Helena Porsch, Jonas Lidholm, Michael R. Goldberg

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review


Background: Oral immunotherapy (OIT) is a treatment option for patients with milk, egg, and peanut allergy, but data on the efficacy and safety of cashew OIT are limited. Methods: A cohort of 50 cashew-allergic patients aged ≥4 years, who were consecutively enrolled into cashew OIT (target dose 4000 mg protein) between 4/2016 and 12/2019. Fifteen cashew-allergic patients who continued cashew elimination served as observational controls. Co-allergy to pistachio and walnut was determined. Full desensitization rate and associated immunological changes in both groups were compared. Patients fully desensitized to cashew were instructed to consume a dose of 1200 mg cashew protein for 6 months and were then challenged to a full dose. Patients with co-allergy to pistachio or walnut were challenged to the respective nut. Results: Forty-four of 50 OIT-treated patients (88%) compared to 0% in controls tolerated a dose of 4000 mg cashew protein at the end of the study (odds ratio 8.3, 95% CI 3.9–17.7, p < 0.001). An additional three patients were desensitized to 1200 mg cashew protein, and three patients stopped treatment. Three patients (6%) were treated with injectable epinephrine for home reactions. Desensitized patients had decreased SPT, sIgE, basophil reactivity, and increased sIgG4, following treatment. Following cashew desensitization, all pistachio (n = 35) and four of eight walnut co-allergic patients were cross-desensitized to the respective nut. All (n = 44) patients consuming a low cashew dose for ≥6 months following desensitization passed a full-dose cashew OFC. Conclusions: Cashew OIT desensitizes most cashew-allergic patients and cross-desensitizes to pistachio. Safety is similar to OIT for other foods.

Original languageEnglish
Pages (from-to)1863-1872
Number of pages10
JournalAllergy: European Journal of Allergy and Clinical Immunology
Issue number6
StatePublished - Jun 2022


FundersFunder number
Ministry of Health, State of Israel


    • allergy
    • cashew
    • cross-reactivity
    • immunotherapy
    • tree nuts


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