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Wheat Allergy: Overview, Diagnosis, and Treatment

Symptoms
Diagnosis
Management
Practice Parameters
Testing Information

About Wheat Allergy

Wheat allergy, an IgE-mediated reaction to the insoluble gliadins of wheat, is one of the most common allergic reactions in children and can be found less commonly in adults.1,2 In patients with food allergies, wheat allergy is diagnosed in 11 to 20 percent of children, and in 25 percent of adults.1 Studies have shown a prevalence of wheat allergy in children of around 0.4 percent.3 A U.S. study estimated the resolution rates of pediatric wheat allergy at 29 percent by the age of 4 years, 56 percent by the age of 8 percent, and 65 percent by the age of 12.3

Depending on the route of exposure, wheat allergy is classified into three main types:3

  • Occupational asthma, also called baker’s asthma and rhinitis.
  • Wheat-dependent exercise-induced anaphylaxis (WDEIA) and contact urticaria.
  • Food allergy affecting the skin, the gastrointestinal tract, or the respiratory tract.

The main routes of sensitization are through oral ingestion of wheat products or inhalation of wheat flour.4

Baker’s asthma and rhinitis are well-characterized allergic responses to the inhalation of wheat flours, affecting up to 10 percent to 15 percent of bakers, millers, and pastry factory workers.3 Some patients may develop symptoms after eating meals contaminated by uncooked wheat flour, but otherwise they do not report problems after the ingestion of cooked wheat.3 Symptoms caused by inhalation of wheat flour include rhinitis, conjunctivitis, and contact urticaria.4

Wheat-dependent, exercise-induced anaphylaxis is a rare condition in which wheat ingestion combined with exercise trigger an anaphylactic-type reaction, leading to angioedema, dyspnea, and shock.1,4 WDEIA It is typically diagnosed in adults and sporadically in older children.1 Symptoms of WDEIA typically occur 10 minutes to 60 minutes after exercise following the ingestion of wheat anywhere from 10 minutes to four hours earlier.1 Once WDEIA occurs, it needs to be treated as wheat-induced anaphylaxis.5

A food allergy to wheat manifests with a variety of symptoms that include urticaria/angioedema, asthma, allergic rhinitis, abdominal pain, vomiting, and acute exacerbation of atopic dermatitis in both children and adults.3,5 Symptoms of food allergy to wheat develop within minutes to up to two hours after the ingestion of wheat.1,5 In young children gastroenterological symptoms, such as vomiting or diarrhea, are most common and peak at age 1 year.1,4 In about 40 percent of children, skin symptoms (e.g., urticaria, erythema, angioedema, pruritus, or worsening atopic dermatitis) are observed.1

Older children suffer mostly from dermatitis, which is accompanied by respiratory disorders (e.g., wheeze, stridor, persistent cough, hoarse voice, respiratory distress, nasal congestion) and, in the most severe cases, anaphylaxis.1 In 45 percent to 50 percent of teenagers and adults, the most severe forms of allergy, including anaphylaxis symptoms, prevail.1 Skin and gastrointestinal symptoms are less common in these age groups.1

11% to 20% of children 

In patients with food allergies, wheat allergy is diagnosed in 11 percent to 20 percent of children, and in 25 percent of adults.1

A food allergy to wheat manifests with a variety of symptoms:1,3-5

  • Urticaria/angioedema
  • Asthma
  • Allergic rhinitis
  • Wheezing
  • Stridor
  • Persistent cough
  • Hoarse voice
  • Abdominal pain
  • Vomiting
  • Acute exacerbation of atopic dermatitis 
  • Diarrhea
  • Erythema
  • Respiratory distress
  • Nasal congestion

The thin line between wheat allergy, celiac disease, and non-celiac gluten sensitivity (NCGS) is not always clearly distinguishable, which can make it difficult to differentiate between these disorders.2

Wheat allergy: Refining differential diagnosis through testing

Like all food allergies, diagnosing a wheat allergy starts with a physical examination and, of critical importance, a food-allergy-focused patient history.6,7

The findings of this wheat-allergy-focused patient history can then be used to guide testing decisions and results interpretation. This systematic approach can help determine whether the reported history of food allergy, combined with specific IgE test and/or skin-prick test, is sufficient to diagnose food allergy, or if an oral food challenge (OFC) should be considered.3,5,8

Wheat allergy and gluten-related disorders

Wheat allergy is one of many gluten-related disorders.1 There are three major wheat-related food illnesses: wheat allergy, celiac disease, and non-celiac gluten sensitivity (NCGS).4 The thin line between wheat allergy, celiac disease, and NCGS is not always clearly distinguishable, which can make it difficult to differentiate between these disorders.2

Although there might be an overlap in the symptoms associated with wheat allergy, celiac disease, and NCGS, the conditions have distinct characteristics, as different mechanisms are involved.3,4 Wheat allergy is distinct from both celiac disease and NCGS in that it is an IgE-mediated response that occurs within minutes to hours of wheat ingestion.4

Who should be tested?

Guidelines recommend that food allergies, including wheat allergy, should be considered in patients presenting with anaphylaxis or a combination of clinical symptoms occurring within minutes to hours after ingesting food, especially in young children or if it is the second episode after the ingestion of specific food.3

Additionally, as wheat allergy’s distinction from both celiac disease and non-celiac gluten sensitivity is that it is an IgE-mediated response, testing can help determine whether the symptoms are actually due to a wheat allergy or another disorder on the gluten-related spectrum.4

Suspected Gluten-Related Disorder Diagnostic Algorithm3

A thorough knowledge of the differences and overlap in clinical presentations among gluten-related disorders can help clinicians in
the process of differential diagnosis following a correct flow chart.

Diagnosis of gluten-related disorders:
A gluten free diet

Food Allergy Algorithm

Diagnosis of gluten-related disorders:
A gluten containing diet

Food Allergy Algorithm

Food Allergy
Diagnostic Algorithm8

Food Allergy Algorithm

Wheat allergy and quality of life

Food allergy, including wheat allergy, can have a dramatic effect on quality of life.10 Many studies have detailed the negative effect of food allergy on health-related quality of life (HRQoL), as well as the financial and emotional toll a food allergy takes.8 Identified issues include feeling different because of the diet, worrying about foods, the presence of physical and emotional distress, increased responsibility, effect on social activities (social restrictions, school, travel, and dining out), anxiety, stress, bullying, and having to consistently exercise greater caution.8 

Common foods and beverages that contain wheat

Many foods may contain wheat, including:11

  • Alcoholic beverages (made from grain alcohol)
    • Ale, beer, wine, bourbon, whiskey, etc.
  • Baked goods
    • Biscuits, breads (including rye bread), cakes, cookies, crackers, etc.
  • Baking mixes
  • Barley bread and drinks
  • Battered foods
  • Bouillon cubes
  • Breaded meats
  • Breaded vegetables
  • Breakfast cereals
  • Candy or chocolate candy
  • Canned processed meat
  • Cereal grains
  • Couscous
  • Gravy
  • Hot dogs
  • Ice cream
  • Ice cream cones
  • Luncheon meats
  • Licorice
  • Malt
  • Malted milks
  • Milk shakes
  • Noodle products
  • Pasta (noodles, spaghetti, macaroni)
  • Pepper (compound or powdered flour filler)
  • Pies
  • Processed meats
  • Sausage
  • Semolina
  • Snack foods 
  • Soup mixes and soups
  • Soy sauce
  • Tablets 

Testing Confidence

Testing Increases Diagnostic Confidence

Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv 

i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238

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Management and care of patients with wheat allergy

Management of wheat allergy is mainly based on avoidance of wheat both in food and inhaled wheat allergens.5 Patients with a food allergy to wheat must be trained to identify relevant food allergens in the labels, and written instruction should be given to help eliminate wheat from their diet.5 In case of accidental exposure and anaphylactic reaction for all forms of wheat allergy, an epinephrine auto-injector can be a lifesaving treatment.5

Practice parameters have been developed to help guide the management and treatment of patients with food allergies, including wheat.

Practice Parameters

Practice parameters and guidelines

for wheat allergy:

Algorithm

Summary of the New Food Allergy Guidelines for Primary Care Physicians (January 2012)

Algorithm

Summary of the New Food Allergy Guidelines for Pediatricians (September 2011)

Algorithm

European Academy of Allergy and Clinical Immunology (EAACI) Food Allergy and Anaphylaxis Guidelines

Algorithm

National Institute for Health and Care Excellence (NICE) food allergy guideline

Algorithm

Management of food allergy in the school setting (AAP clinical report, 2010)

Algorithm

Guidelines for the diagnosis and management of food allergy in the United States: Report of the NIAID-sponsored expert panel (2010)

Algorithm

Food allergy: a practice parameter update (2014)

Read Patient Case Studies
References
  1. Czaja-Bulsa G, Bulsa M. What Do We Know Now about IgE-Mediated Wheat Allergy in Children? Nutrients. 2017 Jan; 9(1): 35.
  2. Biesiekierski JR, Iven J. Non-coeliac gluten sensitivity: piecing the puzzle together. United European Gastroenterol J. 2015 Apr; 3(2): 160–165.
  3. Elli L et al. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World J Gastroenterol. 2015 Jun 21;21(23):7110-9.
  4. Green PH, Lebwhol B, Greywoode R. Celiac Disease. J Allergy Clin Immunol. 2015 May;135(5):1099-106.
  5. Cianferoni A. Wheat allergy: diagnosis and management. J Asthma Allergy. 2016; 9: 13–25.
  6. Kurowski K, Boxer RW. Food allergies: detection and management. Am Fam Physician. 2008;77:1678-1688. 
  7. Burks AW, Tank M, Sicherer S, et al. ICON: Food allergy. J Allergy Clin Immunol. 2012;129:906-920.
  8. Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol. 2018 Jan;141(1):41-58.
  9. Kattan JD, Sicherer SH. Optimizing the Diagnosis of Food allergy. Immunol Allergy Clin North Am. 2015; 35(1): 61–76.
  10. Antolín‐Amérigo et al. Quality of life in patients with food allergy. Clin Mol Allergy. 2016;14:4.
  11. Steinman HA. "Hidden" allergens in foods. J Allergy Clin Immunol. 1996 Aug;98(2):241-50.