Real-life lessons on omalizumab and food allergy: The potential for unexplored outcomes

Introduction: IgE-mediated food allergy (FA) represents an increasing global health burden, with rising prevalence and limited therapeutic options beyond allergen avoidance and emergency management. The approval of omalizumab as the first biologic to reduce reactions after accidental food exposure marks a turning point in FA care. While randomized controlled trials (RCTs) have demonstrated its efficacy in raising reaction thresholds and reducing allergic responses, real-world studies provide complementary evidence capturing outcomes relevant to everyday life. Methods: This review integrates evidence from sources of observational studies, including cohort, case series, and case reports evaluating omalizumab in patients with FA, including complex phenotypes and populations typically excluded from RCTs. Discussion: Real-world data demonstrate that omalizumab can prevent severe reactions in atypical and non-ingestive FA phenotypes, increase reaction thresholds as monotherapy, and enable dietary liberalization in a substantial proportion of patients. Observational cohorts consistently report improvements in food allergy-related quality of life, reduced anxiety, and enhanced confidence in food management. Omalizumab appears effective and well tolerated across complex populations, including patients with multiple comorbidities and very high total IgE levels, even beyond currently approved dosing limits. Emerging evidence also suggests that FA may require disease-specific dosing paradigms distinct from those used in asthma. Conclusions: Real-world evidence complements RCTs findings by highlighting the multidimensional benefits of omalizumab in FA, encompassing clinical protection, dietary freedom, and psychosocial well-being as well as dose fine-tuning and off-label scenarios. These data support its broader clinical value and inform future research, dosing strategies, and personalized application in routine care.