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ALG-003 / 2.0

Cashew and its relationship to pistachio

A new source profile distinguishing cashew clinical evidence from data that cannot be transferred to other preparations.

Collection and scientific editing: Stasinos Chr. SikaliasContent edition: 2.0Record editorial review date: 2026-10-14

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Primary clinical source

NUT CRACKER included 50 cashew-OIT patients and 15 observational controls. Full desensitisation occurred in 44/50 (88%) versus no controls. After cashew desensitisation, the 35 assessed patients with co-existing pistachio allergy were also desensitised to pistachio. Three patients (6%) required injectable epinephrine for home reactions. This was a cohort, not a randomised trial, and the outcome does not establish permanent cure.

Technical identity

Cashew and pistachio remain separate materials and dossiers. Record species, processing, lot and analytical basis. Clinical cross-desensitisation does not permit material substitution or a potency conversion without specific evidence.

Profile use

This profile supports a literature discussion with a specialist. It provides no recipe, thermal process, clinical regimen or BUD. Product development requires a full OIT dossier and study of the actual matrix and package.

Processing and comparability

The additional 2024 laboratory source shows changes in extractable protein profiles after processing. The audit’s technical inference is that changes of form, heat treatment or fraction separation need reassessment. No cashew-to-pistachio equivalence factor or basis for transferring BUD from one to the other is established.

Sources and references

  1. Elizur A et al. Cashew oral immunotherapy for desensitizing cashew-pistachio allergy (NUT CRACKER study)Allergy. 2022;77:1863–1872Abstract, methods and results; PMID 35000223; DOI 10.1111/all.15212Cashew OIT cohort and pistachio cross-desensitisation; no pistachio syrup or peanut suspension stability data2026-10-14
  2. Santos AF et al. EAACI guidelines on the management of IgE-mediated food allergyAllergy. 2025;80:14–36; online 2024Recommendations 8, 9, 12 and 13; desensitisation versus remission/continued treatmentSpecialist clinical recommendations; not stability evidence for local syrups or suspensions2026-10-14
  3. EMA — Guideline on Allergen Products: Production and Quality IssuesEMEA/CHMP/BWP/304831/2007; adopted 20 November 2008; effective 20 May 2009; remains current effective quality version on EMASections 2, 4.1.1, 4.2.4.4, 4.4.3–4.4.5; document pp. 4–13Industrial biological-allergen quality guidance; principles adapted explicitly, not a compounding authorisation or a food-OIT recipe2026-10-14
  4. EMA — Guideline on allergen products development for immunotherapy and allergy diagnosis in moderate to low-sized study populationsEMA/161669/2025; adopted 10 June 2025; effective 1 January 2026Sections 2, 4 and 4.1 (Type I allergy quality aspects); pp. 4–6; section 8.4 for food-allergy endpointsIndustrial allergen development and quality guidance; complements 2008 guideline. Section 4.2 Type IV patch-test exceptions are not transferred to food OIT.2026-10-14
  5. Shwe Yee N et al. Development of Cashew and Pistachio Ladders through a Food-Processing ApproachFoods. 2024;13(21):3440Abstract and figures; DOI 10.3390/foods13213440Primary laboratory processing/extraction and antibody-binding work; no local syrup validation, clinical dose-equivalence factor or BUD.2026-10-14