Quantitative Assessment of the Safety Benefits Associated with Increasing Clinical Peanut Thresholds Through Immunotherapy

The Cost-effectiveness of Omalizumab for Treatment of Food Allergy

BACKGROUND

Omalizumab is an anti-IgE therapy newly approved by the Food and Drug Administration for allergen agnostic treatment of single or multiple food allergies in patients aged 1 year or older.

OBJECTIVE

Evaluate the cost-effectiveness of omalizumab as a food allergy treatment.

METHODS

We evaluated health and economic outcomes in Markov cohorts of simulated food allergic infants randomized to receive omalizumab using a 15-year horizon. Monte Carlo simulation was used (n = 40,000 subjects) to evaluate cost-effectiveness from a societal perspective, incorporating both a family-level and individual-level analysis. We included family-level analysis to incorporate a broad perspective for health utility change, given treatment effects likely benefit all parties at home (eg, caregivers, siblings), not just the patient, representing the sum of changes in all such persons. Supplemental analyses explored lower omalizumab cost and home initiation. We performed deterministic and probabilistic sensitivity analyses.

RESULTS

In the family-level cohort analysis, omalizumab exceeded cost-effectiveness thresholds ($185,183/quality-adjusted life-years [QALY]). In a comparison of the omalizumab strategy (OMA) with the non-omalizumab strategy, the cost of OMA exceeded the non-omalizumab strategy ($315,020 vs $136,609) with greater incremental effectiveness (12.668 vs 11.699 QALY). In the individual-level analysis, the cost-effectiveness of OMA was $573,698/QALY. In base-case assessments, OMA was cost-effective (willingness to pay, $100,000/QALY) at a health state utility (HSU) improvement of 0.265. The value-based cost of OMA ranged from $14,166 to $23,791 when it was considered at the individual and family-unit levels. Requiring OMA administration in the clinic was not cost-effective (incremental cost-effectiveness ratio, $260,239).

CONCLUSIONS

In the base case and at current pricing, omalizumab is not cost-effective, but it could be at a lower retail price or when use creates large health utility shifts in the family and patient.

Safety and efficacy of epicutaneous immunotherapy with DBV712 (peanut patch) in peanut allergy

INTRODUCTION

DBV712 250 µg (also referred to as Viaskin Peanut or peanut patch; Viaskin is a trademark of DBV Technologies) is an innovative approach to epicutaneous immunotherapy (EPIT). The patch-based technology system facilitates peanut protein (allergen) absorption into the intact non-vascularized epidermis to promote desensitization to peanut while limiting systemic allergen exposure.

AREAS COVERED

Efficacy and safety in children have been evaluated in four completed phase 3 studies. Overall, the results from these studies have demonstrated the peanut patch to be superior in desensitization compared with placebo and safe for daily use over multiple years.

EXPERT OPINION

These findings, as well as supportive evidence from phase 2 studies, confirm the potential for an effective treatment of peanut allergy in children. The purpose of this review is to summarize the safety and efficacy of the peanut patch in the treatment of peanut allergy.

Evaluation of clinical outcomes of efficacy in food allergen immunotherapy trials, COFAITH EAACI task force

Food allergy is a global public health problem that until recent years lacked any aetiological treatment supported by academy, industry and regulators. Food immunotherapy (AIT) is an evolving treatment option, supported by clinical practice and industry trial data. Recent AIT meta-analyses have highlighted the difficulty in pooling safety and efficacy data from AIT trials, due to secondary heterogeneity in the study. An EAACI task force (CO-FAITH) initiated by the Paediatric Section was created to focus on AIT efficacy outcomes for milk, egg and peanut allergy rather than in trial results. A systematic search and a narrative review of AIT controlled clinical trials and large case series was conducted. A total of 63 manuscripts met inclusion criteria, corresponding to 23, 21 and 22 studies of milk, egg and peanut AIT, respectively. The most common AIT efficacy outcome was desensitization, mostly defined as tolerating a maintenance phase dose, or reaching a particular dose upon successful exit oral food challenge (OFC). However, a large degree of heterogeneity was identified regarding the dose quantity defining this outcome. Sustained unresponsiveness and patient-reported outcomes (e.g. quality of life) were explored less frequently, and to date have been most rigorously described for peanut AIT versus other allergens. Change in allergen threshold assessed by OFC remains the most common efficacy measure, but OFC methods suffer from heterogeneity and methodological disparity. This review has identified multiple heterogeneous outcomes related to measuring the efficacy of AIT. Efforts to better standardize and harmonize which outcomes, and how to measure them must be carried out to help in the clinical development of safe and efficacious food allergy treatments.

Utility of food allergy thresholds

Food allergy is a prevalent disease worldwide that is a significant quality-of-life burden, and accidental exposures to food allergens may elicit severe, life-threatening reactions such as anaphylaxis. The threshold level, or the dose that triggers an allergic reaction determined by oral food challenges, varies considerably among individuals suffering from food allergies. Moreover, IgE concentration, diversity, or function can only partially explain this variation in threshold; pathogenic effector TH2 cells have also been found to contribute to the eliciting dose. Though very sensitive to cofactors such as physical activity/stress, the threshold is a stable and reproducible feature of an individual's allergy over periods of many months, made clear in the past several years from treatment studies in which repeated threshold determination has been used as a treatment outcome; however, there also seem to be age-related changes at a population level. More routine determination of food allergy thresholds may help patients stratify risk to improve the management of their food allergy. Precautionary allergen labeling, such as "may contain" labels, often causes confusion since they are inconsistent and regularly contain little to trace allergen residues; thus, food products with such labeling may be unnecessarily avoided. Population-based eliciting dose levels have been determined in the literature; patients at lower risk with higher thresholds may be more confident with introducing foods with precautionary allergen labels. Understanding a patient's threshold level could aid in shared decision-making to determine the most suitable treatment options for patients, including the starting dose for oral immunotherapy and/or the use of biologics.

Real-world safety and effectiveness analysis of low-dose preschool sesame oral immunotherapy

Background

Previous studies support the effectiveness of sesame oral immunotherapy (S-OIT) in patients >4 years old using maintenance doses of 1200 mg protein. However, tahini is often not palatable to children, and high-maintenance doses may not be possible for preschoolers.

Objective

We studied the safety and effectiveness outcomes of preschoolers with sesame allergy who underwent low-dose S-OIT of 200 mg protein.

Methods

Preschoolers with sesame allergy, with a history of objective reaction to sesame, and with either a positive skin prick test result (wheal diameter ≥3 mm) or sesame-specific IgE level ≥0.35 kU/L were included. Doses were escalated every 2 to 4 weeks until the maintenance dose of 200 mg of sesame protein was reached. The maintenance dose was continued daily for 1 year, followed by exit oral food challenge (OFC). Primary safety outcomes included allergic reactions grade 2 or higher and the need for epinephrine therapy during buildup. The primary effectiveness outcome was proportion of patients tolerating a minimum of 2000 mg sesame protein at exit OFC.

Results

Twenty-eight preschoolers (median age, 33.5 months) were enrolled to receive S-OIT. During the buildup phase, 9 subjects (32.1%) had no reaction, and 8 (28.6%) and 11 (39.3%) had grade 1 and 2 reactions, respectively. One patient (3.57%) received epinephrine for a grade 2 reaction. Twenty-one (91.3%) of 23 eligible subjects underwent exit OFC; 18 (85.7%) of these 21 patients successfully completed exit OFC. One (4.8%) and 2 (9.5%) subjects had grade 1 and 2 reactions, respectively, during OFC.

Conclusions

A lower and age-appropriate maintenance dose is safe and effective in desensitizing preschoolers with sesame allergy.

Food Allergen Immunotherapy in the Treatment of Patients with IgE-Mediated Food Allergy

The prevalence of allergic diseases, including food allergy, is increasing, especially in developed countries. Implementation of an elimination diet is not a sufficient therapeutic strategy in patients with food allergy, whose quality of life is significantly impaired. In recent years, new effective therapeutic strategies have been developed, such as the application of oral, sublingual, and epicutaneous immunotherapy. Oral immunotherapy is the most often applied strategy because of its effectiveness and ease of application, with an acceptable safety profile. The effectiveness of oral immunotherapy in patients with egg, cow's milk, and peanut allergy has been proven both in terms of raising of the threshold and the development of tolerance, and in some patients, the development of sustainable unresponsiveness. Although oral immunotherapy is an effective treatment for food allergy, several limitations, including a long duration and a significant rate of reported adverse events, reduces its success. Therefore, new therapeutic options, such as treatment with biologicals, either as combinations with food allergen immunotherapy or as monotherapy with the aim of improving the efficacy and safety of treatment, are being investigated.

Food Immunotherapy: Dissecting Current Guidelines and Navigating the Gray Zone

Food allergy is a common, chronic disease that is burdensome for patients and families, with multiple dietary and social limitations and a significant psychological impact stemming from the fear of accidental exposures and potentially severe, life-threatening reactions. Until recently, the only management option consisted of strict food avoidance. Food allergen immunotherapy (food AIT) has emerged as an alternative, active intervention to strict food avoidance, with a multitude of research studies supporting its efficacy and good safety profile. Food AIT results in a raise of allergenic threshold, which provides several benefits to food-allergic patients, including protection from accidental exposures, potentially decreased severity of allergic reactions on unintentional exposures, and improvement in quality of life. In the last few years, multiple independent reports have been published proposing strategies to implement food oral immunotherapy in U.S. clinics, although formal guidelines are currently lacking. Because food immunotherapy is gaining traction, popularity, and interest among both patients and health care providers, many physicians look for guidance on how to implement this intervention in their daily practice. In other parts of the world, use of this treatment has prompted the development of various guidelines from allergy societies. This rostrum discusses currently available guidelines on food AIT from different areas of the world, describes and comments on their similarities and differences, and highlights unmet needs in this area of therapy.

Association of Reaction Symptoms and Eliciting Dose With Health-Related Quality of Life in Children With Peanut Allergy

BACKGROUND

Food allergy adversely affects the health-related quality of life (HRQoL) of patients. It is unclear whether factors such as the reaction eliciting dose (ED) and the nature of allergic reaction symptoms affect HRQoL.

OBJECTIVE

To explore associations between reaction ED or the nature of allergic symptoms and HRQoL among children with peanut allergy.

METHODS

This study was a secondary analysis of baseline data from the PPOIT-003 randomized trial in 212 children aged 1 to 10 years with challenge-confirmed peanut allergy. Children's past reaction symptoms were collected by clinicians during screening. Associations between variables of interest and parent-reported child-proxy HRQoL were examined by univariable and multivariable linear regression.

RESULTS

Mean age of study participants was 5.9 years; 63.2% were male. Children with a low reaction ED of 80 mg peanut protein had significantly poorer HRQoL (β = -0.81; 95% CI, -1.61 to -0.00; P = .049) compared with children with a high ED of 2,500 mg peanut protein. Gastrointestinal symptoms (β = 0.45; 95% CI, 0.03-0.87; P = .037), lower airway symptoms (β = 0.46; 95% CI, 0.05-0.87; P = .030), multisystem involvement (β = 0.71; 95% CI, 0.25-1.16; P = .003), or anaphylaxis (β = 0.46; 95% CI, 0.04-0.87; P = .031) during a previous reaction were associated with worse HRQoL.

CONCLUSIONS

Peanut-allergic children with a lower allergen reaction threshold experienced a greater negative HRQoL impact compared with children with higher reaction thresholds. In addition, specific past allergic reaction symptoms were associated with comparatively worse HRQoL. Children experiencing these symptoms and those with lower reaction ED require increased clinical support to manage the food allergy and are likely to benefit from interventions that can improve HRQoL.

Immune response evolution in peanut epicutaneous immunotherapy for peanut-allergic children

BACKGROUND

Epicutaneous immunotherapy with investigational Viaskin™ Peanut 250 μg (DBV712) has demonstrated statistically superior desensitization versus placebo in peanut-allergic children in clinical trials. It is unclear whether serologic biomarkers predict response.

METHODS

Serum-specific IgG4 and IgE (whole peanut and components) from subjects enrolled in the phase 3 Efficacy and Safety of Viaskin Peanut in Children With IgE-Mediated Peanut Allergy study were examined by exploratory univariate and multivariate analyses to determine trajectories and predictors of treatment response, based upon peanut protein eliciting dose (ED) at Month (M) 12 double-blind placebo-controlled food challenge.

RESULTS

Among Viaskin Peanut-treated subjects, peanut sIgG4 significantly increased from baseline through M12 and peanut sIgE peaked at M3 and fell below baseline by M12, with sIgG4 and sIgE peanut components mirroring these trajectories. Placebo subjects had no significant changes. By univariate analysis, M12 peanut sIgG4/sIgE was higher in treatment responders (p < 0.001) and had highest area under the curve (AUC) for predicting ED ≥300 mg and ≥1000 mg (AUC 69.5% and 69.9%, respectively). M12 peanut sIgG4/sIgE >20.1 predicted M12 ED ≥300 mg (80% positive predictive value). The best performing component was Ara h 1 sIgE <15.7 kUA /L (AUC 66.5%). A multivariate model combining Ara h 1 and peanut sIgG4/sIgE had an AUC of 68.2% (ED ≥300 mg) and 67.8% (ED ≥1000 mg).

CONCLUSIONS

Peanut sIgG4 rise most clearly differentiated Viaskin Peanut versus placebo subjects. sIgG4/sIgE ratios >20.1 and the combination of Ara h 1 and peanut sIgG4/sIgE had moderate ability to predict treatment response and could potentially be useful for clinical monitoring. Additional data are needed to confirm these relationships.

A phase II study of Bruton's tyrosine kinase inhibition for the prevention of anaphylaxis

BACKGROUNDIgE-mediated anaphylaxis is a potentially fatal systemic allergic reaction for which there are no currently FDA-approved preventative therapies. Bruton's tyrosine kinase (BTK) is an essential enzyme for IgE-mediated signaling pathways and is an ideal pharmacologic target to prevent allergic reactions. In this open-label trial, we evaluated the safety and efficacy of acalabrutinib, a BTK inhibitor that is FDA approved to treat some B cell malignancies, in preventing clinical reactivity to peanut in adults with peanut allergy.METHODSAfter undergoing graded oral peanut challenge to establish their baseline level of clinical reactivity, 10 patients had a 6-week rest period, then received 4 standard doses of 100 mg acalabrutinib twice daily and underwent repeat food challenge. The primary endpoint was the change in patients' threshold dose of peanut protein to elicit an objective clinical reaction.RESULTSAt baseline, patients tolerated a median of 29 mg of peanut protein before objective clinical reaction. During subsequent food challenge on acalabrutinib, patients' median tolerated dose significantly increased to 4,044 mg (range 444-4,044 mg). 7 patients tolerated the maximum protocol amount (4,044 mg) of peanut protein with no clinical reaction, and the other 3 patients' peanut tolerance increased between 32- and 217-fold. 3 patients experienced a total of 4 adverse events that were considered to be possibly related to acalabrutinib; all events were transient and nonserious.CONCLUSIONAcalabrutinib pretreatment achieved clinically relevant increases in patients' tolerance to their food allergen, thereby supporting the need for larger, placebo-controlled trials.TRIAL REGISTRATIONClinicalTrials.gov NCT05038904FUNDINGAstraZeneca Pharmaceuticals, the Johns Hopkins Institute for Clinical and Translational Research, the Ludwig Family Foundation, and NIH grants AI143965 and AI106043.

Low-Dose Oral Challenge Test in Pediatric Patients With Peanut Allergy: Tolerance Assessment of a Trace 5 mg Peanut Test After Symptom Induction With a 500 mg Test

Introduction Peanut allergy (PA) represents a significant public health concern, particularly prevalent in Western countries. Children at high risk for PA may undergo a low-dose oral food challenge (OFC). However, if the result is positive, complete elimination of peanuts from the diet is recommended, and further trace OFC is typically not performed.  Material and methods This cross-sectional study retrospectively examined the rate of positive peanut OFC with a total peanut load of 5 mg in children who tested positive with a total peanut load of 500 mg. Patient information was gathered from medical records. The primary endpoint was the rate at which children who tested positive in the OFC with 500 mg of peanut butter also tested positive with 5 mg of peanut butter equivalent.  Results Among 32 children who underwent an OFC with a total peanut load of 500 mg, two were excluded for not meeting the criteria. Among the remaining 30 children, 14 (46.7%) had a positive 500 mg peanut OFC test, and three (10%) experienced an anaphylactic reaction. Those who tested positive for the OFC had higher peanut-specific and Ara h2-specific immunoglobulin E (IgE) antibodies. An OFC with 5 mg of peanuts performed on 10 of the 14 patients who tested positive for 500 mg of peanuts showed no positive results. Conclusion The results of this study suggest that children with severe PA who exhibit positive symptoms to a total peanut load of 500 mg can tolerate a 5 mg dose of peanuts and should be considered for an OFC.

Open-label study of the efficacy, safety, and durability of peanut sublingual immunotherapy in peanut-allergic children

BACKGROUND

Studies on the efficacy of peanut sublingual immunotherapy (SLIT) are limited. The durability of desensitization after SLIT has not been well described.

OBJECTIVE

We sought to evaluate the efficacy and safety of 4-mg peanut SLIT and persistence of desensitization after SLIT discontinuation.

METHODS

Challenge-proven peanut-allergic 1- to 11-year-old children were treated with open-label 4-mg peanut SLIT for 48 months. Desensitization after peanut SLIT was assessed by a 5000-mg double-blind, placebo-controlled food challenge (DBPCFC). A novel randomly assigned avoidance period of 1 to 17 weeks was followed by the DBPCFC. Skin prick test results immunoglobulin levels, basophil activation test results, TH1, TH2, and IL-10 cytokines were measured longitudinally. Safety was assessed through patient-reported home diaries.

RESULTS

Fifty-four participants were enrolled and 47 (87%) completed peanut SLIT and the 48-month DBPCFC per protocol. The mean successfully consumed dose (SCD) during the DBPCFC increased from 48 to 2723 mg of peanut protein after SLIT (P < .0001), with 70% achieving clinically significant desensitization (SCD > 800 mg) and 36% achieving full desensitization (SCD = 5000 mg). Modeled median time to loss of clinically significant desensitization was 22 weeks. Peanut skin prick test; peanut-specific IgE, IgG4, and IgG4/IgE ratio; and peanut-stimulated basophil activation test, IL-4, IL-5, IL-13, IFN-γ, and IL-10 changed significantly compared with baseline, with changes seen as early as 6 months. Median rate of reaction per dose was 0.5%, with transient oropharyngeal itching being the most common, and there were no dosing symptoms requiring epinephrine.

CONCLUSIONS

In this open-label, prospective study, peanut SLIT was safe and induced clinically significant desensitization in most of the children, lasting more than 17 weeks after discontinuation of therapy.

Clinical outcomes of efficacy in food allergen immunotherapy trials

PURPOSE OF REVIEW

With food allergy affecting millions of children worldwide, the consolidation of food allergen immunotherapy represents an encouraging therapeutic option, that might expand in the next few years to reach greater number of candidates. This review aims at providing a critical overview of the efficacy outcomes employed in food allergen immunotherapy trials (AIT).

RECENT FINDINGS

Understanding efficacy endpoints rely on identifying what and how these are being measured. Desensitization, as the efficacy of the therapy to increase the patient's reactivity threshold to the food during therapy, and Sustained Unresponsiveness, withholding such efficacy even if the therapy is withdrawn, are nowadays considered the main parameters of efficacy evaluation. Quality of life is a promising variable to capture food AIT impact from the patient's perspective.There is a relevant degree of heterogeneity across studies in outcomes definitions and also in oral food challenges design, the tool that is more spread to assess results, hampering study comparison.

SUMMARY

Interpreting the results of a clinical trial, and comparing data from different studies is an important task, both for the researcher and the clinician, that should be done after a careful analysis of the outcomes and the evaluation tools used.

Post hoc analysis examining symptom severity reduction and symptom absence during food challenges in individuals who underwent oral immunotherapy for peanut allergy: results from three trials

PURPOSE

Peanut allergy and its current management, involving peanut avoidance and use of rescue medication during instances of accidental exposure, are burdensome to patients and their caregivers and can be a source of stress, uncertainty, and restriction. Physicians may also be frustrated with a lack of effective and safe treatments other than avoidance in the current management of peanut allergy. Efficacy, determined using double-blind, placebo-controlled food challenges (DBPCFCs), of oral immunotherapy with peanut (Arachis hypogaea) allergen powder-dnfp (PTAH; Palforzia^®) was demonstrated versus placebo in children and adolescents aged 4 to 17 years in multiple phase 3 trials; continued benefit of PTAH was shown in a follow-on trial. The DBPCFC is a reproducible, rigorous, and clinically meaningful assessment accepted by regulatory authorities to evaluate the level of tolerance as an endpoint for accidental exposures to peanut in real life. It also provides useful clinical and patient-relevant information, including the amount of peanut protein an individual with peanut allergy can consume without experiencing dose-limiting symptoms, severity of symptoms, and organs affected upon ingestion of peanut protein. We explored symptoms of peanut exposure during DBPCFCs from phase 3 and follow-on trials of PTAH to further characterize treatment efficacy from a perspective relevant to patients, caregivers, and clinicians.

METHODS

Symptom data recorded during screening and/or exit DBPCFCs from participants aged 4 to 17 years receiving PTAH or placebo were examined post hoc across three PTAH trials (PALISADE [ARC003], ARC004 [PALISADE follow-on], and ARTEMIS [ARC010]). The maximum peanut protein administered as a single dose during DBPCFCs was 1000 mg (PALISADE and ARTEMIS) and 2000 mg (ARC004). Symptoms were classified by system organ class (SOC) and maximum severity. Endpoints were changes in symptom severity and freedom from symptoms (ie, asymptomatic) during DBPCFC. Relative risk (RR) was calculated for symptom severity by SOC and freedom from symptoms between groups; descriptive statistics were used to summarize all other data.

RESULTS

The risk of any respiratory (RR 0.42 [0.30-0.60], P < 0.0001), gastrointestinal (RR 0.34 [0.26-0.44], P < 0.0001), cardiovascular/neurological (RR 0.17 [0.08-0.39], P < 0.001), or dermatological (RR 0.33 [0.22-0.50], P < 0.0001) symptoms was significantly lower in participants treated with PTAH versus placebo upon exposure to peanut at the end of the PALISADE trial (ie, exit DBPCFC). Compared with placebo-treated participants (23.4%), the majority (76.3%) of PTAH-treated participants had no symptoms at the exit DBPCFC when tested at the peanut protein dose not tolerated (ie, reactive dose) during the screening DBPCFC. Significantly higher proportions of PTAH-treated participants were asymptomatic at doses ≤ 100 mg in the exit DBPCFC compared with placebo-treated participants (PALISADE: 69.35% vs 12.10%, RR 5.73 [95% confidence interval (CI) 3.55-9.26]; P < 0.0001; ARTEMIS: 67.42% vs 13.95%, RR 4.83 [95% CI 2.28-10.25]; P < 0.0001); findings were similar at peanut protein doses ≤ 1000 mg (PALISADE: RR 15.56 [95% CI 5.05-47.94]; P < 0.0001; ARTEMIS: RR 34.74 [95% CI 2.19-551.03]; P < 0.0001). In ARC004, as the period of PTAH maintenance became longer, greater proportions of participants were asymptomatic at doses of peanut protein ≤ 1000 mg in the exit DBPCFC (from 37.63% after ~ 6 months of maintenance treatment [exit DBPCFC of PALISADE] to 45.54% after ~ 13 months and 58.06% after ~ 20 months of overall PTAH maintenance treatment).

CONCLUSIONS

PTAH significantly reduced symptom severity due to exposure to peanut, which is clinically relevant. When exposed to peanut, participants with peanut allergy treated with PTAH rarely had moderate or severe respiratory or cardiovascular/neurological symptoms. Oral immunotherapy with PTAH appears to reduce frequency and severity of allergic reactions in individuals with peanut allergy after accidental exposure to peanut and may enable them and their families to have an improved quality of life. Trial registration ClinicalTrials.gov, NCT02635776, registered 17 December 2015, https://clinicaltrials.gov/ct2/show/NCT02635776?term=AR101&draw=2&rank=7 ; ClinicalTrials.gov, NCT02993107, registered 08 December 2016, https://clinicaltrials.gov/ct2/show/NCT02993107?term=AR101&draw=2&rank=6 ; ClinicalTrials.gov, NCT03201003, registered 22 June 2017, https://clinicaltrials.gov/ct2/show/NCT03201003 ? term = AR101&draw = 2&rank = 9.

Oral immunotherapy for food allergy: Translation from studies to clinical practice?

Oral immunotherapy (OIT) is now recognized as an alternative active treatment to strict food avoidance in certain patients with IgE-mediated food allergy. Studies have confirmed the efficacy of OIT to desensitize children with allergy to cow's milk, eggs, and peanuts. The benefits, risks, and constraints of OIT are becoming increasingly well understood. However, there is no consensual criteria to select patients to whom OIT could be proposed, and many issues remain to address including the definitions of desensitization and long-term efficacy, the assessment of patient's experience in real life, the optimization of buildup and maintenance protocols, and the utility of multiple food OIT. The recent authorization by medical agency concerning the first medicine for peanut OIT is a step forward towards higher standardization in the practice of OIT. This article summarizes in comprehensive narrative format data on efficacy, tolerance, impact on quality of life and adverse effects of OIT and discuss elements to consider in clinical practice before starting OIT.

Precautionary Allergen Labeling: What Advice Is Available for Health Care Professionals, Allergists, and Allergic Consumers?

In most countries, the use of precautionary allergen labeling (PAL) is not governed by regulation. PAL was initially identified as a judicious risk management measure to address instances of "unavoidable" cross-contact with priority food allergens during food processing. However, PAL has gradually been devalued in part due to overuse and inconsistent application by the food industry. Currently, most food products do not contain detectable allergen residue or contain only low concentrations of residue of the allergens declared using PAL; however, occasionally, high concentrations of allergen residue are reported, rendering it an ineffective risk communication tool for allergic consumers. In this context, several reasons exist that make the consumption of products bearing a PAL statement not advisable for people with food allergies. The main reason is that the risk is generally not correlated with the statement used by manufacturers. Because of the increased use of PAL on prepackaged food products, and to maximize food choices for allergic individuals, health care professionals increasingly advise some patients considered to be "not highly allergic" to consume products bearing a PAL statement. This article explains why the consumption of products with PAL is not advisable without having a full clinical evaluation and knowledge that an allergen risk assessment has been conducted. It also discusses the perspectives for a better use of PAL on the basis of the recent Food and Agricultural Organization/World Health Organization recommendations on food allergens.

The Case for Prompt Salvage Infant Peanut Oral Immunotherapy Following Failed Primary Prevention

Recent guideline recommendations have shifted from recommending prolonged avoidance of allergenic foods in the first 3 years of life to a primary prevention approach involving the deliberate early introduction to infants at risk of developing food allergy. Despite this, some infants, especially those with severe eczema who are at highest risk for developing peanut allergy, fail to receive the preventative benefits of early peanut introduction due to hesitancy and other factors. Difficulty adhering to regular ingestion after introduction further reduces the effectiveness of primary prevention. As emerging real-world evidence has demonstrated that performing peanut oral immunotherapy (OIT) among infants is effective and safe, peanut OIT could be a treatment option for infants with peanut allergy. This review discusses the benefits, risks, and barriers to offering peanut OIT to infants who fail primary prevention strategies. We propose the novel concept that infants with peanut allergy be offered peanut OIT as soon as possible after failed peanut introduction through a shared decision-making process with the family, where there is a preference for active management rather than avoidance.

Transitioning peanut oral immunotherapy to clinical practice

Peanut allergy is on the rise in industrialized countries, affecting 1%–4.5% of children and generally persisting into adulthood. It is associated with a risk of severe anaphylaxis and is one of the major causes of food allergy-induced deaths. Health-related quality of life is significantly impaired for patients and affected families due to food restrictions attributable to omnipresent precautionary allergen labeling, constant risk of potentially life-threatening reactions, and limitation of social activities. Oral immunotherapy (OIT) has emerged as a valid treatment option for patients with IgE-mediated peanut allergy, with randomized controlled trials and real-life studies showing a high rate of desensitization and a favorable safety profile, especially in young children. Ultimately, the decision to initiate peanut OIT relies on a multidisciplinary shared decision-making process, involving open, personalized and evidence-based discussions with patients and their caregivers.

Long term oral immunotherapy management and assessment of success

There is limited data addressing the optimal dose, dosing frequency, and duration of OIT maintenance. Using higher maintenance doses, more frequent dosing, and a long dosing duration makes it more likely that sustained unresponsiveness will be achieved but also increases the burden of care on the OIT patient and family. The OIT maintenance regimen should be individualized based on the treatment goals of the patient and family.

Determination of Allergen Levels, Isoforms, and Their Hydroxyproline Modifications Among Peanut Genotypes by Mass Spectrometry

The recently published reference genome of peanuts enables a detailed molecular description of the allergenic proteins of the seed. We used LC-MS/MS to investigate peanuts of different genotypes to assess variability and to better describe naturally occurring allergens and isoforms. Using relative quantification by mass spectrometry, minor variation of some allergenic proteins was observed, but total levels of Ara h 1, 2, 3, and 6 were relatively consistent among 20 genotypes. Previously published RP-HPLC methodology was used for comparison. The abundance of three Ara h 3 isoforms were variable among the genotypes and contributed to a large proportion of total Ara h 3 where present. Previously unpublished hydroxyproline sites were identified in Ara h 1 and 3. Hydroxylation did not vary significantly where sites were present. Peanut allergen composition was largely stable, with only some isoforms displaying differences between genotypes. The resulting differences in allergenicity are of unknown clinical significance but are likely to be minor. The data presented herein allow for the design of targeted MS methodology to allow the quantitation and therefore control of peanut allergens of clinical relevance and observed variability.

Peanut cross-contamination in randomly selected baked goods

BACKGROUND

The current standard of care for managing peanut allergy includes avoidance of peanut and use of injectable epinephrine; however, strict avoidance is difficult and accidental ingestion is common with potentially serious consequences. Despite vigilance and efforts to minimize the risk of accidental exposure, peanut protein cross-contamination continues to occur in a variety of foods, including baked goods.

OBJECTIVE

To assess and quantify the presence of peanut protein contamination in certain baked goods.

METHODS

Randomly selected baked goods were collected from bakeries in the New York and Miami metropolitan areas that sold a variety of ethnic cuisines. A second set of samples from the same bakeries was collected at least 1 week after to evaluate between-batch variability. Samples were sent to the Food Allergy Research and Resource Program to analyze peanut contamination by enzyme-linked immunosorbent assay. Consumption estimates were based on 2003 to 2010 National Health and Nutrition Examination Survey survey data.

RESULTS

Of 154 samples from 18 bakeries, 4 (2.6%) had detectable peanut contamination with peanut protein levels ranging from 0.1 mg/100 g to 650 mg/100 g. Consumption estimates for single occasion ingestion of a contaminated item ranged from 0.07 mg to 832 mg of peanut protein.

CONCLUSION

In this study, unintended peanut protein was present in a small, but not insignificant, proportion of baked goods, with the potential to trigger a reaction in individuals with peanut allergy. Some products contained high levels of unintended peanut protein. The current data support the potential for accidental exposure to peanut protein with its associated risk.

The Effector Function of Allergens

Allergens are antigens that generate an IgE response (sensitization) in susceptible individuals. The allergenicity of an allergen can be thought of in terms of its ability to sensitize as well as its ability to cross-link IgE/IgE receptor complexes on mast cells and basophils leading to release of preformed and newly formed mediators (effector activity). The identity of the allergens responsible for sensitization may be different from those that elicit an allergic response. Effector activity is determined by (1) the amount of specific IgE (sIgE) and in some circumstances the ratio of sIgE to total IgE, (2) the number of high affinity receptors for IgE (FcεR1) on the cell surface, (3) the affinity of binding of sIgE for its epitope and, in a polyclonal response, the collective avidity, (4) the number and spatial relationships of IgE binding epitopes on the allergen and (5) the presence of IgG that can bind to allergen and either block binding of sIgE and/or activate low affinity IgG receptors that activate intracellular inhibitory pathways. This review will discuss these important immunologic and physical properties that contribute to the effector activity of allergens.

Sesame as an allergen in Lebanese food products: Occurrence, consumption and quantitative risk assessment

Despite the intensive use of sesame in the Middle Eastern diet, studies on this allergen in this region are lacking. A survey on the occurrence of sesame in Lebanese food products that did not contain this allergen as an ingredient, a food consumption survey conducted in Beirut schools, and the most recent sesame eliciting dose estimates were used to build a probabilistic risk assessment model providing estimates of sesame-induced allergic reactions per eating occasion and per week in Lebanese children and adolescents. Of 1270 food samples analysed, 34% contained sesame proteins (0.44-3392 mg kg^-1). Sesame was detected in 47% of unlabeled bulk samples, 43% of samples with PAL, and 27% of samples without PAL. "Sfouf" had the highest concentration of sesame proteins (mean 549 mg kg^-1), highest mean exposure per eating occasion (78 mg sesame proteins for children and 103 mg sesame proteins for adolescents), and posed the highest predicted risk per eating occasion (>20%) and per week (>13% individuals predicted in simulation experience at least 1 reaction). Bakery products (notably "sfouf") may pose a serious risk to sesame-allergic children and adolescents in Lebanon. Enhanced guidance on the use of PAL is needed to better protect allergic consumers.

The Risk Reduction of Accidental Exposure-Related Systemic Allergic Reactions Extrapolated Based on Food Challenge Data After 1 Year of Peanut Oral Immunotherapy

Introduction

The phase 3 trial PALISADE, comparing peanut (Arachis hypogaea) allergen powder-dnfp (PTAH) oral immunotherapy versus placebo in peanut-allergic children, reported that a significantly higher percentage of PTAH-treated participants tolerated higher doses of peanut protein after 1 year of treatment. This study used PALISADE data to estimate the reduction in the risk of systemic allergic reaction (SAR) after accidental exposure following 1 year of PTAH treatment.

Methods

Participants (aged 4–17 years) enrolled in PALISADE were included. Parametric interval-censoring survival analysis with the maximum likelihood estimation was used to construct a real-world distribution of peanut protein exposure using lifetime SAR history and highest tolerated dose (HTD) from a double-blind, placebo-controlled food challenge conducted at baseline. The SAR risk reduction was extrapolated using the exposure distribution and the HTD were collected at baseline and trial exit for PTAH- and placebo-treated participants.

Results

Assuming a maximum peanut protein intake of 1500 mg, participants were estimated to have < 1% probability of ingesting > 0.01 mg during daily life. The mean annual SAR risk at trial entry was 9.25–9.98%. At trial exit, the relative SAR risk reduction following accidental exposure was 94.9% for PTAH versus 6.4% for placebo. For PTAH-treated participants with exit HTD of 600 or 1000 mg without dose-limiting symptoms, the SAR risk reduction increased to 97.2%. The result was consistent in the sensitivity analysis across different parametric distributions.

Conclusion

Oral immunotherapy with PTAH is expected to result in a substantially greater reduction in risk of SAR following accidental exposure compared to placebo among children with peanut allergy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-01843-2.

Latest Developments in the Management of Nut Allergies

Purpose of review

In this review, we sought to describe the most recent advances in the dietary and medical management of peanut and tree nut allergy, including selective introduction and immunotherapy.

Recent findings

Dietary updates include changes to labeling laws, improved information sources, and new apps for buying foods in shops and overseas to better protect individuals with nut allergies. There are still issues in the management of nut allergies in schools, such as parents having to resort to packed lunches instead of school meals and patients experiencing bullying. Air travel also poses concern, but additional resources are now available to travelers, and recent evidence suggest limited airborne exposure to nuts. The medical management of anaphylaxis is use of epinephrine; however, this remains underutilized. Needle length and administration devices have been recently debated considering the risk of bone penetration vs subcutaneous administration, and autoinjectors seem to deliver higher peak concentrations than syringes. Selective nut introduction has gained momentum in the last 5 years, demonstrating improved quality of life but with the need for motivated parents for continued consumption and available resources for challenges. Immunotherapy to nuts is also a rapidly developing field, with the balance of efficacy and safety being important considerations in the differing modes of administration.

Summary

The management of nut allergies is a rapidly developing field, and dietary and medical management have progressed significantly in the last 5 years. Future research directions include improving safety and efficacy of food immunotherapy and examining patients’ goals for therapy and treatment outcomes.

Treatment Approaches to Food Allergy

IgE-mediated food allergies affect both children and adults and are associated with dramatic decreases in the quality of life. In the majority of cases, food allergens have to be avoided which may be difficult, particularly in patients who suffer from life-threatening symptoms following the ingestion of minimal doses of food allergens. Several novel therapeutic approaches have been studied during the recent past and are summarized in this review. Therapies with novel therapeutic monoclonal antibodies, innovative allergen-specific immunotherapies using subcutaneous, sublingual, or epicutaneous routes, and oral immunotherapies leading to increases of individual thresholds of tolerable foods upon their continuous ingestion showed promising results which may change future management strategies in moderate to severe food allergy.

Heterogeneity in Parent Preferences for Peanut Desensitization Therapy

BACKGROUND

Recently developed peanut desensitization treatment reduces the incidence of allergic reactions, the anxiety associated with the risk of accidental exposure, and the burden of precautionary behavior. Eliciting parent preferences for tradeoffs involving treatment effectiveness, tolerability, costs, and convenience quantifies the burden of juvenile peanut allergy and the perceived value of peanut desensitization therapies.

OBJECTIVE

To understand heterogeneity in parents' treatment preferences and the role of personal characteristics in explaining differences.

METHODS

An Internet-based, discrete-choice experiment survey was administered to a national sample of 500 parents of children aged 4 to 17 years with peanut allergy to quantify parents' preferences for peanut desensitization therapies for their children. Latent-class, mixed-logit analysis estimated relative importance coefficients for groups of participants with distinctly different preferences.

RESULTS

Parents' choice patterns fell into 1 of 4 preference subgroups: (1) Cost-sensitive, (2) Protreatment (but Side-Effect-Averse), (3) Trader, and (4) Inconsistent. Mode of administration had little relative importance across all subgroups. Characteristics associated with belonging to a given preference subgroup included parent age, child age, income, parent perception of child risk and ability to manage allergic reactions, past allergic reactions, and changes in precautionary behaviors posttreatment.

CONCLUSIONS

We found distinct differences in parent preferences for tradeoffs involving effectiveness, tolerability, and costs of peanut desensitization treatments. Parents' treatment preferences help quantify the burden of juvenile peanut allergy and the perceived value of new therapies. Such information can inform patient-centric clinical and regulatory decision making.

Peanut oral immunotherapy in a pediatric allergy clinic: Patient factors associated with clinical outcomes

BACKGROUND

Additional information is needed to inform optimal patient selection, expected outcomes, and treatment end points for clinical peanut oral immunotherapy (OIT).

OBJECTIVE

To provide insight into the optimal patient selection, expected outcomes, and treatment end points for clinical peanut oral immunotherapy by analyzing a real-world peanut OIT cohort.

METHODS

Records were reviewed for 174 children undergoing peanut OIT at a pediatric allergy clinic. Patient age, peanut skin prick test results, and peanut-specific immunoglobulin E (sIgE) results, with inclusion of additional foods in OIT, were analyzed for correlations with OIT outcomes.

RESULTS

To date, 144 patients have achieved maintenance dosing, 50 of whom transitioned to ad lib twice-weekly peanut ingestion. A total of 30 discontinued OIT. In addition, 47 patients who underwent multifood OIT had no significant difference in reactions (FDR-adjusted P = .48) or time-to-reach maintenance (FDR-adjusted P = .48) compared with those on peanut OIT alone. Age at initiation inversely correlated with achievement of maintenance: 92% of patients 0.5 to less than 5 years, 81% of those 5 to less than 11 years, and 70% of those 11 to less than 18 years reached and continued maintenance (P = .01). Baseline peanut-sIgE level positively correlated with number of reactions during updosing (P < .001) and maintenance (P = .005), though it was not significantly different in patients achieving successful maintenance vs those who discontinued OIT (P = .09). Furthermore, 66% of patients experienced greater than or equal to 1 adverse reaction during OIT. Of those on ad lib peanut ingestion, 2 reported mild reactions after lapses in peanut consumption.

CONCLUSION

Clinical peanut OIT has similar outcomes to research protocols. OIT can be successful in older children and those with high peanut-sIgE levels, though these factors affect outcomes. Clinical and laboratory criteria can guide successful transition to intermittent ad lib peanut consumption.

The importance of the 2S albumins for allergenicity and cross-reactivity of peanuts, tree nuts, and sesame seeds

Allergies to peanuts, tree nuts, and sesame seeds are among the most important food-related causes of anaphylaxis. Important clinical questions include: Why is there a variable occurrence of coallergy among these foods and Is this immunologically mediated? The clinical and immunologic data summarized here suggest an immunologic basis for these coallergies that is based on similarities among the 2S albumins. Data from component resolved diagnostics have highlighted the relationship between IgE binding to these allergens and the presence of IgE-mediated food allergy. Furthermore, in vitro and in vivo experiments provide strong evidence that the 2S albumins are the most important allergens in peanuts for inducing an allergic effector response. Although the 2S albumins are diverse, they have a common disulfide-linked core with similar physicochemical properties that make them prime candidates to explain much of the observed coallergy among peanuts, tree nuts, and sesame seeds. The well-established frequency of cashew and pistachio nut coallergy (64%-100%) highlights how the structural similarities among their 2S albumins may account for observed clinical cross-reactivity. A complete understanding of the physicochemical properties of the 2S albumins in peanuts, tree nuts, and sesame seeds will enhance our ability to diagnose, treat, and ultimately prevent these allergies.

A Practical, Stepwise Approach to Peanut Oral Immunotherapy in Clinical Practice: Benefits and Risks

Food allergies are common, affecting 6–8% of the children in the United States. There is a significant burden on the quality of life of allergic children and their caregivers, due to multiple dietary, social and psychological restrictions. Peanut allergy affects approximately 2–5% of the school-age children. Despite the recommended dietary avoidance, reactions tend to occur due to unintentional exposures and the fear of accidental ingestions potentially resulting in anaphylaxis and death, which creates a lot of anxiety in peanut-allergic individuals. Peanut oral immunotherapy (POIT) has emerged as a form of active treatment and has shown high efficacy in research trials with the majority of participants achieving desensitization and protection from trace exposures. An improved quality of life has also been noted following successful POIT. The risks of POIT should be balanced against the benefits resulting from successful treatment for each individual. Rates of allergic reactions and anaphylaxis are reported to be higher in individuals pursuing therapy, but most subjects will experience mild or moderate reactions during treatment. The landscape of peanut allergy management is changing and the future offers more options for patients than were previously available. Shared decision-making, which is the process of how to choose between different available options, becomes an ongoing discussion between the clinician and the patient, which will ensure achievement of the best possible outcome for the peanut-allergic child. This is a multistep process that evaluates the benefits and risks of therapy or no therapy, as well as patient and family preferences and we review it in detail in this manuscript with the aim to provide clinicians with a practical approach.

Epicutaneous immunotherapy for treatment of peanut allergy: Follow-up from the Consortium for Food Allergy Research

BACKGROUND

Consortium for Food Allergy Research investigators previously reported 52-week outcomes from a randomized controlled trial of peanut epicutaneous immunotherapy, observing modest and statistically significant induction of desensitization, highest in children ages 4 to 11 years.

OBJECTIVE

We sought to evaluate changes in efficacy, safety, and mechanistic parameters following extended open-label peanut epicutaneous immunotherapy.

METHODS

Peanut-allergic participants (4-25 years) received 52 weeks of placebo (PLB), Viaskin Peanut 100 μg (VP100) or 250 μg (VP250), and then crossed over to VP250 for PLB (PLB-VP250) and VP100 (VP100-VP250) participants and continued treatment for VP250 participants (total = 130 weeks of active epicutaneous immunotherapy). Efficacy was assessed by double-blind, placebo-controlled food challenge (5044 mg peanut protein), and adherence, safety, and mechanistic parameters were evaluated.

RESULTS

At week 130, desensitization success was achieved in 1 of 20 (5%) PLB-VP250, 5 of 24 (20.8%) VP100-VP250, and 9 of 25 (36%) VP250 participants, with median successfully consumed dose change from baseline of 11.5 mg, 141.5 mg, and 400 mg, respectively. Median age (years) for week 130 desensitization success was 6.2 years (interquartile range, 5.2-9.1) versus 9.4 years (interquartile range, 7.6-12.8) for failures (P < .001). Adherence was 96%. Adverse reactions were predominantly local patch-site reactions. Significant increases in peanut- and Ara h2-specific IgG4 observed at week 52 persisted to week 130. By a post hoc analysis, there were no statistically significant increases from week 52 to week 130 in either desensitization success or successfully consumed dose.

CONCLUSIONS

Extended treatment with VP250 was well tolerated, and desensitization observed at week 52 persisted between weeks 52 and 130. Treatment success was observed predominantly in younger participants, with younger age at initiation of active therapy an important predictor of success.

Weighing the benefits and risks of oral immunotherapy in clinical practice

Food allergies are common and affect 6-8% of children in the United States; they pose a significant burden on the quality of life of children with allergy and their caregivers due to multiple daily restrictions. Despite the recommended dietary avoidance, reactions tend to occur due to unintentional exposure to the allergenic food trigger. Fear of accidental ingestions with potentially severe reactions, including anaphylaxis and death, creates anxiety in individuals with food allergy. Oral immunotherapy has emerged as a form of active and potentially disease-modifying treatment for common food allergies encountered in childhood. The efficacy of oral immunotherapy is high, with the majority of participants achieving desensitization and, as a result, protection from trace exposures and improved quality of life. The main risk of oral immunotherapy consists of allergic reactions to treatment. In general, rates of allergic reactions and anaphylaxis are reported to be higher in individuals pursuing therapy options, but most subjects who undergo oral immunotherapy will likely experience mild or moderate reactions during treatment. Adverse events tend to reduce in both frequency and number in the maintenance period. The use of immune modulators alongside oral immunotherapy has been suggested, with the aim to improve efficacy and safety, and to facilitate the overall process. It is evident that the landscape of food allergy management is changing and that the future looks brighter, with different options emerging over time. The process of how to choose the appropriate option becomes a discussion between the clinician and the patient, which involves a joint review of the current medical evidence but also the patient's preference for balancing particular attributes of the treatment. By working together, providers and patients will ensure achievement of the best possible outcome for children with food allergies.

Current Insights into Immunotherapy Approaches for Food Allergy

In the last decade, there has been increasing research dedicated to food immunotherapy to induce clinical desensitization and provide protection by increasing clinical reaction thresholds. Results from recent food immunotherapy studies with differing routes of administration (oral, sublingual, and epicutaneous) suggest that food immunotherapy can induce clinical desensitization with varying levels of safety, however lasting tolerance has not been demonstrated. Furthermore, treatment side effects and dosing logistics may make the therapies difficult for some supporting the need for alternative treatment approaches. Peptide immunotherapy and DNA vaccine approaches should in theory allow for safer administration by decreasing allergenicity but proof of their clinical efficacy and immunogenicity remains to be proven. Biologic agents may allow for increased safety and rapid up-dosing of immunotherapy with the added benefit of treating multiple allergens simultaneously.

Characteristics of Peanut Allergy Diagnosis in a US Health Care Claims Database (2011-2017)

BACKGROUND

Peanut allergy is the most common food allergy among children. Studies assessing the burden of peanut allergy in a real-world setting are limited.

OBJECTIVE

To estimate annual incidence and prevalence of peanut allergy cases among children aged 4 to 17 years and assess severe reaction and associated health care utilization rates.

METHODS

Patient longitudinal data between January 2011 and December 2017 from a geographically and payer-type representative US health care claims database were used. Peanut allergy cases were identified using diagnostic codes and/or services indicating peanut-allergy-associated severe reactions/anaphylaxis. Estimated annual incidence was defined as peanut-allergic births as a proportion of all 1-year-olds and adjusted for less than 100% data set capture, undercoding, patient underpresenting rates, and spontaneous outgrowth. Prevalence was calculated on the basis of incidence. To assess rates of severe reactions to peanut and associated health care utilization, the cohort of 720,490 peanut allergy cases identified in 2011 was evaluated over a 6-year period from 2011 to 2017.

RESULTS

Annual incidence increased from 1.7% to 5.2% between 2001 and 2017. Estimated prevalence in 4- to 17-year-olds was 1.25 million (2.2%) in 2017. Atopic comorbidities (asthma, 60.8%; atopic dermatitis, 61.7%) and other food allergies (35.3%) were common. Severe reactions (≥1) were observed in more than half (n = 399,806) the patients, and 37.9% were triggered by an accidental exposure. One in 5 patients (n = 144,883) visited the emergency department due to peanut exposure.

CONCLUSIONS

Claims data suggest that the incidence and prevalence of peanut allergy in the United States may be increasing. Estimated severe reaction rates and health care utilization were high, suggesting that the burden of peanut allergy may be considerable.

First Real-World Effectiveness Analysis of Preschool Peanut Oral Immunotherapy

BACKGROUND

We previously described safety of preschool peanut oral immunotherapy (P-OIT) in a real-world setting; 0.4% of patients experienced a severe reaction, and 4.1% received epinephrine, during build-up.

OBJECTIVE

To determine the effectiveness of preschool P-OIT after 1 year of maintenance.

METHODS

Preschoolers (9-70 months) with at least 1 objective reaction to peanut (during baseline oral food challenge (OFC) or P-OIT build-up) received a follow-up OFC to cumulative 4000 mg protein after 1 year on 300 mg peanut daily maintenance. Effectiveness of desensitization was defined as proportion of patients with a negative follow-up OFC. Symptoms and treatment at follow-up OFC were recorded.

RESULTS

Of the 117 patients who successfully completed 1 year of P-OIT and subsequently underwent a cumulative 4000-mg follow-up OFC, 92 (78.6%) had a negative OFC and 115 (98.3%) tolerated a cumulative dose of greater than or equal to 1000 mg. For the 25 (21.4%) who reacted, their threshold increased by 3376 mg (95% CI, 2884-3868) from baseline to follow-up; 17 (14.5%) patients experienced grade 1 reactions, 7 (6.00%) grade 2, and 1 (0.85%) grade 3. Two patients (1.71%) received epinephrine associated with P-OIT, and 1 (0.85%) went to the emergency department.

CONCLUSIONS

Our data demonstrate that real-world preschool P-OIT is effective after 1 year of maintenance for those who received a follow-up OFC. For those who reacted, their threshold increased sufficiently to protect against accidental exposures. P-OIT should be considered for preschoolers as an alternative to current recommendations to avoid peanut.

Oral immunotherapy for peanut allergy: The pro argument

Food allergy (FA) is a growing public health problem with personal, social, nutritional, and economic consequences. In the United States, it is estimated that 8% of children and 10.8% of adults have food allergies. Allergies to peanuts are particularly worrisome as unlike allergies to other allergenic foods, such as milk and egg, which are commonly outgrown by 5 or 10 years of age, 80% of peanut allergies persist into adulthood. The first drug for peanut allergy, Palforzia, was approved by the US Food and Drug Administration (FDA) in January 2020. For other food allergies, the current standard of care for the management of FA is suboptimal and is limited to dietary elimination of the offending allergen, vigilance against accidental ingestion, and treatment of allergic reactions with antihistamines and epinephrine. However, dietary avoidance can be challenging, and it is estimated that approximately 40% of patients with food allergies report at least one food allergy-related emergency department in their lifetime. Reactions, even from minimal exposures, can be life-threatening.

Oral immunotherapy (OIT) has been the best researched therapeutic approach for treating FA over the last decade, with clinical trials investigating its efficacy, safety, and ability to improve participants' quality of life (QoL). A number of studies and meta-analyses have shown that OIT treatment is effective in raising the threshold of reactivity to peanuts and other foods in addition to producing a measurable serum immune response to such therapy. Although OIT-related adverse events (AEs) are common during treatment, serious reactions are rare. In fact, while the majority of patients experience AEs related to dosing, most continue daily dosing in hopes of achieving protection against the culprit food. Moreover, the majority of participants report improvement of QoL after OIT and are positive about undergoing OIT. These results show patients’ commitment to OIT and their optimism regarding the benefits of treatment. As a first step in therapeutic options to protect from reactions to unintentional ingestion of allergenic foods, and importantly, to address the many psychosocial aspects of living with FA, OIT shows promise. Future research will focus on identifying optimal OIT regimens that maintain protection after therapy and allow for regular food consumption without allergic symptoms. Education and informed shared decision making between patients and providers are essential in optimizing current therapy regimens.

Food allergy: Epicutaneous immunotherapy

The goal of allergen-specific immunotherapy for treatment of immunoglobulin E (IgE) mediated food allergy is to safely and effectively modify the allergic response, providing protection against anaphylaxis via ongoing exposure to the triggering allergen. Targeted allergen exposure via application of allergen to the epidermis has emerged as a potentially promising approach to desensitization. Epicutaneous immunotherapy (EPIT) uses allergen embedded on an adhesive patch secured to the skin. This allows for long-lasting allergen exposure, with subsequent antigen uptake and trafficking by skin antigen-presenting cells to regional lymph nodes, which produce immunomodulatory effects in a manner that is noninvasive and limits exposure of allergen to the systemic circulation when applied to intact skin. As such, EPIT is overall well tolerated; local application site reactions are common, but systemic adverse effects are infrequent compared with other forms of immunotherapy. For peanut allergy, EPIT may increase the dose-triggering threshold in some individuals with peanut-allergy, especially younger children, but induction of remission has not been closely studied, and reliable predictors of clinical response are lacking. With U.S. Food and Drug Administration approved treatment for peanut allergy now available, the precepts of shared decision-making will be crucial in discussions with patients and their families with regard to treatment options.

Risk of shared equipment in restaurants for consumers with peanut allergy: a simulation for preparing Asian foods: A simulation for preparing Asian foods

BACKGROUND

Allergic reactions to meals consumed outside the home are common and can be severe and sometimes fatal.

OBJECTIVE

To quantify the risk reduction potentially achieved by increasing an individual's threshold sensitivity to peanut (such as by means of immunotherapy) in scenarios of peanut exposure through shared kitchen materials in a restaurant setting.

METHODS

Three versions of popular peanut-containing sauces were selected to represent common ingredients used in Asian cooking. Different combinations of utensils, equipment, sauces, and test conditions were prepared by a professional chef, with or without common cleaning procedures, to represent normal daily practice. Residue amounts of peanut-containing material on kitchen equipment and utensils were measured and used for quantitative risk assessment to model the risk reduction associated with increasing an individual's threshold.

RESULTS

Shared utensils had mean residue amounts of 23 to 1519 mg peanut protein (no cleaning) and 3 to 82 mg peanut protein (after water rinse). Shared woks and pans had up to 20 mg peanut protein after rinsing. Individuals who reach a threshold of 300 mg peanut protein have a predicted relative risk reduction of 94.9% to greater than 99.99% with brief cleaning. With no cleaning, relative risk reductions were 63.5% to 91.1% for individuals with a baseline threshold of less than or equal to 100 mg peanut protein who reach a threshold of 300 mg peanut protein, increasing to 91% to 99.7% when reaching a threshold value of 1000 mg peanut protein.

CONCLUSION

In all shared kitchen material scenarios that we studied, achieving an eliciting dose of 300 or 1000 mg peanut protein seems clinically relevant for the peanut-allergic population.

Can my child with IgE-mediated peanut allergy introduce foods labeled with "may contain traces"?

Peanut IgE-mediated food allergy is one of the most common food allergies in children with a prevalence that has increased in the past decades in Westernized countries. Peanut allergies can trigger severe reactions and usually persist over time. Peanut-allergic children and their families are often confronted to processed foods with precautionary allergen labeling (PAL) such as "may contain traces of peanuts," which are frequently used by the food industry. Patients are generally confused as to whether eating such foods entails a risk of allergic reaction, which can ultimately lead to dietary restrictions and decreased quality of life. Thus, guidance toward eviction of foods with PALs such as "may contain traces of peanuts" is a recurring problem that peanut-allergic patients address during pediatric allergy consultations with varying attitudes among allergists. Many studies have evaluated peanut contamination in foods with PALs, with generally less than 10% of foods containing detectable levels of peanuts, albeit heterogeneous amounts, with in rare occasions levels that could trigger allergic reactions in certain patients. The risk of reacting to foods with traces varies significantly with threshold, with patients with the lowest reaction thresholds at highest risk, and a dramatic reduction of risk as threshold increases. Thus, risk stratification based on individual reaction threshold may help stratify patients' risk of reacting to foods with PAL. In clinical practice, a single-dose 30 mg peanut protein oral food challenge may be an option to stratify peanut-allergic patients' risk when introducing foods with PAL, as illustrated by three clinical cases.