COMMENTARY

5 Best of 2019: Most-Read Pediatrics Viewpoints

William T. Basco, Jr, MD, MS

Disclosures

January 21, 2020

#3: Is Oral Immunotherapy for Peanut Allergy Ready for Prime Time?

A US Food and Drug Administration (FDA) advisory panel recently unanimously recommended approval of a first-in-class oral agent for use in children with peanut allergy. If approved by the FDA, which is expected, the product will be indicated to reduce the likelihood of anaphylaxis after accidental peanut exposure in children aged 4-17 years with a confirmed peanut allergy.

The PALISADE trial , a recent, large (66 international sites), double-blind, placebo-controlled, randomized trial, sought to determine whether a test agent containing 300 mg of peanut protein could produce desensitization. The investigators found that use of peanut (Arachis hypogaea) allergen powder (Palforzia) produced a clinically and statistically significant large difference in the proportion of children who could tolerate the final peanut protein challenge. Two thirds of children who received the treatment were able to ingest the final dose of 600 mg of peanut protein (the equivalent of approximately two peanuts), compared with only 4% of the placebo group. Over three quarters were able to tolerate 300 mg or "one peanut" (76.6% vs 8.1%).

Viewpoint

Oral immunotherapy will be a terrific advance and hopefully will allay the terror of parents who fear their child may accidentally ingest a food contaminated with peanuts. But it will not lead to formerly allergic children being able to eat a peanut butter sandwich. And it will come with risks. Notably, rescue epinephrine was still needed during the final food challenge in 1 out of 10 of the children treated. Although this is markedly less than the 50% of children in the placebo group who required rescue, it is still a substantial number and demonstrates that this process should be carefully monitored. For now, that means that this may not be the purview of primary care physicians.

A second caution is that the drug will require daily dosing for 12 months, and that will be difficult to maintain for many. How long protection might last should therapy be discontinued is another unanswered question.

Finally, long-term ingestion of even low-doses of peanut powder by a child who is sensitive to it could induce other allergic disease, including mucosal eosinophilia, down the line. For a broader review of where the evidence stands on desensitization for peanut allergy, check out a review published in the autumn of 2019.

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