Taste aversion and adverse events contribute equally to OIT discontinuation in children: A real-world multi-allergen analysis.

BACKGROUND: Although oral immunotherapy (OIT) is a promising disease-modifying treatment, its real-world effectiveness is limited by the treatment burden and premature cessation. Comparative data on OIT discontinuation across allergens and non-immunological barriers remain scarce. This study investigated the rates, reasons, and timing of discontinuation in a pediatric multi-allergen cohort and identified patient phenotypes. METHODS: In this single-center observational study, pediatric patients initiating OIT between July 2022 and March 2026 were prospectively enrolled. Reasons for discontinuation were documented at cessation and supplemented by chart review. Causes were categorized as adverse events (AE) or non-AE factors (taste aversion, logistical barriers, anxiety/distress). Baseline characteristics were compared, and hierarchical clustering identified phenotypes. RESULTS: Among 406 OIT courses in 307 patients, 61 (15%) were discontinued. Rates were highest for milk and lowest for cashew and sesame. AE and taste aversion were the most frequent reasons for discontinuation (41% (n = 25) and 39% (n = 24), respectively), followed by logistical barriers (11%, n = 7) and anxiety/distress (8%, n = 5). AE-related discontinuation occurred earlier in the treatment, whereas taste aversion predominated during maintenance and across ages. Patients discontinuing due to AE had higher baseline sIgE. Multi-food OIT was not associated with increased discontinuation. Exploratory cluster analysis identified three phenotypes; the high-risk cluster (high sIgE, prior severe reactions, low reactive dose) showed taste aversion as the leading cause of discontinuation. CONCLUSION: Discontinuation in this real-world cohort was driven equally by AE and behavioral barriers. Taste aversion emerged as a key determinant of adherence, including in younger patients. Improving OIT success requires patient-centered strategies addressing both immunological and practical barriers.