# Kiwifruit Allergy--Molecular Basis, Diagnostics and Treatment
## 7 Management of Kiwifruit Allergies  
The general principles of management for all allergic diseases also apply to this group of patients. There are three areas of action: allergen avoidance, pharmacotherapy, and allergen immunotherapy. In kiwifruit allergy, management strongly depends on the clinical presentation, which may range from benign PFAS to severe, life-threatening anaphylaxis [70].  
In patients with a history of PFAS, ideally supported by the demonstration of sensitization to unstable proteins such as PR-10s or profilins, but not to stable proteins such as nsLTP, 2S albumins, or actinidin, complete abstinence from kiwifruit consumption is not necessary [110]. Moreover, meals containing processed kiwifruit usually do not trigger an allergic response in such patients [5].  
Should symptoms triggered by accidental exposure to raw kiwifruit appear, the use of oral H1 antihistamines such as citirazine or loratadine should be effective in reducing the severity of symptoms [110]. However, it is usually not advised to use pretreatment with H1 antihistamines to consume foods known to trigger PFAS. If PR-10-dependent PFAS is demonstrated, particularly in patients who experience birch pollen allergy, allergen immunotherapy to birch may improve the tolerance of kiwifruit in some patients, but this is not a guarantee [65; 110].  
It is worth emphasizing that component-resolved diagnosis may be helpful in determining the risk of more severe clinical reactions upon kiwifruit ingestion in patients who have reported only local responses [111].  
Patients that experienced anaphylaxis upon kiwifruit ingestion should undergo a careful evaluation of potential allergen sources, ideally at the molecular level, to provide sufficient information concerning food avoidance methods, including the assessment of the potential impact of food processing on the risk of anaphylaxis upon the ingestion of different kiwifruit-containing meals [112]. Moreover, searching for co-factors that affect the appearance of anaphylaxis upon kiwifruit ingestion and/or affect its intensity is highly warranted [113]. Cases of food-dependent exercise-induced anaphylaxis to kiwifruit have been described [16].  
All patients who have experienced anaphylaxis should be equipped with epinephrine autoinjectors and be instructed how to use them [112]. Allergen immunotherapy with kiwifruit extract is not commercially available. However, kiwifruit-induced allergy and anaphylaxis have been successfully treated with sublingual immunotherapy containing extracts from kiwifruit [114].  
Thermal treatment of fruit was reported to be effective in the reduction in allergic reactions to kiwifruit [115]. In a trial that involved 20 children, it was found that thermally processed kiwifruit elicited responses in only five of the children when SPTs was used, while all 20 participants reacted to raw fruit [115]. Later, it was also confirmed that structurally intact and non-denatured kiwifruit allergens that were resistant to digestion could be responsible for systemic reactions [115]. It was also suggested that patients with hypoacidic medical conditions may have impaired the pepsin digestion of kiwifruits and therefore may have an increased risk of allergic reactions. Interestingly, it was also shown that, while the heat-induced denaturation of Act d 1 was not reversible when the allergen was transferred to an acidic solution, this was not true in the case of Act d 2 [44]. However, recent studies suggest that the microwave processing of kiwifruit may reduce its allergenity related to the presence of Act d 2 [116].