Private practice clinical experience with peanut oral immunotherapy

Published online: April 2, 2020

Food allergies are a major health concern in the United States. The prevalence of food allergies has been increasing over the past decades with peanut and tree nut allergy now affecting approximately 2% of the population. Our patients have been anxiously waiting for an effective treatment for food allergies, and we are now entering an exciting time where several options are on the horizon. In multiple trials and clinical practice experiences, oral immunotherapy emerged as an effective treatment for peanut allergies, but questions remain regarding the safety of this approach.

In a recent article published in The Journal of Allergy and Clinical Immunology: In Practice by Afinogenova et al, report on their experience with peanut oral immunotherapy in over 700 peanut allergic children and adults at the New England Food Allergy Treatment Center in West Hartford, CT. In their retrospective study, they examined a large collection of patient data, analyzed adverse reactions experienced during build up and maintenance treatment phases and identified factors that may contribute to these adverse events.

Although the majority of patients experienced skin, respiratory or gastrointestinal reactions, the number of serious events necessitating epinephrine use, visit to the emergency room, new medication, or cessation of therapy was relatively low. During the build-up phase, 10% had at least one systemic reaction, 84% had at least one gastrointestinal reaction, 47% at least one skin and 20% at last one respiratory adverse reaction with 4% requiring epinephrine. During the maintenance phase, the rate of participants with at least one adverse reaction per type was: systemic (19%), gastrointestinal (27%), cutaneous (15%) and respiratory (7%). During maintenance, 11% required epinephrine. None of the reactions resulted in hospitalization or fatality. Increasing pre-treatment peanut specific IgE was associated with increased systemic reactions in build-up and maintenance phases; increasing age and presence of a systemic reaction in build-up were associated with increased systemic reactions in maintenance phase.

In this large single center study, the authors showed that peanut oral immunotherapy is associated with a somewhat higher risk of systemic reactions compared to an avoidance strategy, but they emphasize that the approach eliminates the element of complete unpredictability as would be expected with accidental ingestions. The authors propose that peanut oral immunotherapy may be an effective and safe treatment for carefully selected peanut allergic patients under the guidance of experienced providers. Specific patient characteristics and immunological factors may help predict occurrence of adverse events on therapy.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

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