Peanut Allergy: Hope on the Horizon

Peanut allergy is not an issue only within the health care community—it is a hot topic of discussion and often discord among parents, teachers, legislators, and media commentators. Unintentional exposure can be lifethreatening for individuals who have a peanut allergy, which sometimes leads affected families to request controversial peanut bans at school. Avoiding peanuts and peanut-containing foods is just part of the inconvenience; children with food allergies are often bullied and experience a certain stigma when they require helicopterlike supervision in restaurants, at sporting events, and during social activities.

Since 1997, peanut allergy incidence has increased 5-fold among children. About 1.6 million children are affected, more than 40% of whom have required an emergency department visit. Private payers indicate that claims for anaphylactic peanut reactions increased 445% between 2007 and 2016.

At the Asembia Specialty Pharmacy Summit 2019, peanut allergy and its repercussions generated great interest. Christina E. Ciaccio, MD, MSc, chief of allergy/immunology and pediatric pulmonology and director of the food allergy program at the University of Chicago Medicine, described how food allergies seem to develop.

Among children who have food allergies of any kind, peanut is extremely common, affecting 37% of these individuals. With no FDA-approved treatments for peanut allergy, patients must follow a strict limitation diet and keep an epinephrine autoinjector handy at all times.

Promising treatments are in the pipeline, according to Michael S. Blaiss, MD, clinical professor of pediatrics at Medical College of Georgia at Augusta University. These therapies, which include oral immunotherapy, epicutaneous immunotherapy, and biologics, do not cure peanut allergy but lead to desensitization, which helps protect the patient from a severe anaphylactic reaction set off by accidental ingestion of peanuts.

“There have been years of clinical trials trying to come up with effective and safe treatments to improve the quality of life of the patient with peanut allergy,” he said.

Blaiss then described studies that have shown efficacy. In particular, great strides are being made in oral immunotherapy, which has found to protect from accidental ingestion of 1 to 4 peanuts. Up-dosing of peanut protein takes place every 2 weeks in the allergist’s office until reaching 300 mg—equivalent to 1 peanut—a dose that is continued weekly. Adverse effects are primarily gastrointestinal.

Another type of desensitization in development: epicutaneous immunotherapy, which delivers 250 mcg of peanut in a single daily dose patch. The treatment’s efficacy can be proved only by an oral challenge. Individuals who use the patch might develop mild to moderate skin reactions at the application site, which is expected. All patients on these treatments still need to carry an autoinjector of epinephrine because they are not cured.

“Patients and families will likely have 2 or 3 treatment options in the future. Decisions about what is best for any individual need to be shared among the patient, the patient’s caregiver, and the prescriber,” Ciaccio said. “Certainly ‘avoidance only’ will remain a reasonable option to deal with peanut allergy. Once approved, though, oral immunotherapy or epicutaneous immunotherapy will be options that may increase safety and quality of life when used in addition to avoidance.”

Clinicians must be prepared to discuss benefits and risks, the actual value of treatment, and the cost and time commitment.