Updating the CoFAR Grading Scale for Systemic Allergic Reactions in Food Allergy

R. Sharon Chinthrajah, Stacie M. Jones, Edwin H. Kim, Scott H. Sicherer, Wayne Shreffler, Bruce J. Lanser, Negin Atri, Denise C. Babineau, Daniel C. Adelman, Ahmar Iqbal, Susan L. Limb, Amanda K. Rudman Spergel, Alkis Togias, Robert A. Wood

Research output: Contribution to journalArticlepeer-review

22 Scopus citations


Background: Immunotherapy is promising as an efficacious treatment for food allergy. Other food allergy treatments are also under development. However, adverse allergic events during treatment, as well as during oral food challenges, are common and reporting is not standardized. Objective: A more nuanced grading scale is needed to create a comprehensive and universal system to categorize adverse events and their severity for food allergy clinical trials. Methods: Starting with the 2012 Consortium for Food Allergy Research (CoFAR) Grading Scale and the World Allergy Organization Grading System, we developed the CoFAR Grading Scale for Systemic Allergic Reactions, Version 3.0, in collaboration with industry partners with expert opinion. Results: The revised CoFAR Grading Scale for Systemic Allergic Reactions has 5 levels of increasing severity, ranging from generalized urticaria, localized angioedema, rhinitis, and abdominal pain (grade 1) to death (grade 5). Systemic reactions are further categorized within each grade by relevant organ system. Mild, single-system reactions are differentiated from mild, multisystem reactions. Lower respiratory tract symptoms are graded on the basis of response to therapy; those that are refractory to standard treatment (eg, requiring >3 doses of intramuscular epinephrine, continuous intravenous epinephrine infusion, and continuous albuterol nebulization) and respiratory compromise requiring mechanical ventilation are classified as grade 4, life-threatening reactions. Conclusions: Universal and consistent use of the revised CoFAR Grading Scale beyond the CoFAR centers would allow for better data aggregation and safety comparisons in clinical trials for food allergy.

Original languageEnglish
Pages (from-to)2166-2170.e1
JournalJournal of Allergy and Clinical Immunology
Issue number6
StatePublished - Jun 2022


  • CoFAR
  • Food allergy
  • anaphylaxis
  • grading
  • oral food challenge
  • oral immunotherapy
  • severity scale


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