The management of peanut allergy

Nuts, vegetables, fruits, and protein dietary pattern during pregnancy is inversely associated with risk of childhood allergies: a case-control study

Allergic diseases are prevalent chronic conditions among children and can lead to significant health and economic issues. It is hypothesized that healthy and high quality diet during pregnancy can prevent the onset of allergic diseases in offspring. This study aimed to investigate the potential relationship between major dietary patterns during pregnancy and allergies in children under one year of age. This case-control study was conducted involving 244 participants (122 mothers of allergic children and 122 healthy controls) who visited pediatricians and allergy outpatient clinics in Khuzestan Province, Iran, between June 2022 and March 2023. Demographic information was recorded using a socio-demographic questionnaire. A food frequency questionnaire was used to identify the foods consumed during pregnancy. Major dietary patterns were extracted using principal component analysis, and the potential relationship between these patterns and childhood allergies was investigated using multivariable logistic regression models. The crude odds ratio (OR) analysis showed that the fourth quartile of "Nut, vegetables, fruits, and protein" dietary pattern was associated with lower occurrence of childhood allergies (OR: 0.214, 95% CI = 0.068-0.679; P trend = 0.211). After adjusting for cofactors in Model 3, this association was still observed in the fourth quartile (OR = 0.108, 95% CI = 0.019-0.613; P trend, 0.001). However, no significant association was observed between "Carbohydrate and cereals" and "Salty" dietary patterns and childhood allergies. The study findings suggest that a maternal dietary pattern rich in nuts, vegetables, and fruits during pregnancy may reduce the risk of allergic diseases in offspring.

Oral immunotherapy using boiled peanuts for treating peanut allergy: An open-label, single-arm trial

BACKGROUND

Peanut allergy affects 1%-3% of children in Western countries. Boiling peanuts has been demonstrated to result in a hypoallergenic product that may provide a safer way of inducing desensitization in peanut-allergic patients by first inducing tolerance to boiled peanut. We aimed to assess the efficacy and safety of oral immunotherapy (OIT) using sequential doses of boiled peanuts followed by roasted peanuts for treating peanut allergy in children.

METHODS

In this open-label, phase 2, single-arm clinical trial, children aged 6-18 years with a positive history of peanut allergy and positive peanut skin prick test ≥ 8 mm and/or peanut-specific IgE ≥ 15 kU/L at screening underwent OIT involving sequential up-dosing with 12-hour boiled peanut for 12 weeks, 2-hour boiled peanut for 20 weeks and roasted peanut for 20 weeks, to a target maintenance dose of 12 roasted peanuts daily.

PRIMARY OUTCOME

proportion of children passing open-label oral food challenge involving cumulative administration of 12 roasted peanuts (12 g peanuts; approximately 3000 mg peanut protein) 6-8 weeks after reaching the target maintenance dose. Secondary outcomes included treatment-related adverse events and use of medications for treating allergy symptoms.

RESULTS

Between 1 July 2017 and 22 June 2018, 70 participants were enrolled and commenced OIT. Desensitization was successfully induced in 56 of 70 (80%) participants. Withdrawal due to treatment-related adverse events was infrequent (n = 3). Treatment-related adverse events were reported in 43 (61%) participants, corresponding to a rate of 6.58 per 1000 OIT doses. Medication use associated with treatment-related adverse events was infrequent, with rescue epinephrine use reported by three (4%) participants (0.05 per 1000 doses).

CONCLUSION

Oral immunotherapy using boiled followed by roasted peanuts represents a pragmatic approach that appears effective in inducing desensitization and is associated with a favourable safety profile.

Irradiation technology: An effective and promising strategy for eliminating food allergens

Food allergies are one of the major health concerns worldwide and have been increasing at an alarming rate in recent times. The elimination of food allergenicity has been an important issue in current research on food. Irradiation is a typical nonthermal treatment technology that can effectively reduce the allergenicity of food, showing great application prospects in improving the quality and safety of foods. In this review, the mechanism and remarkable features of irradiation in the elimination of food allergens are mainly introduced, and the research progress on reducing the allergenicity of animal foods (milk, egg, fish and shrimp) and plant foods (soybean, peanut, wheat and nuts) using irradiation is summarized. Furthermore, the influencing factors for irradiation in the elimination of food allergens are analyzed and further research directions of irradiation desensitization technology are also discussed. This article aims to provide a reference for promoting the application of irradiation technology in improving the safety of foods.

The Peanut Allergy Burden Study: Impact on the quality of life of patients and caregivers

Background

Peanut allergy (PA) places significant burden on peanut-allergic individuals and their families, yet limited research in the United States has quantitatively examined the impact on peanut-allergic individuals and their families' health-related quality of life (HRQoL). The Peanut Allergy Burden Study (PABS) aimed to quantify the impact of PA on the general and disease-specific HRQoL of children, adolescents, and adults with PA, as well as caregivers of children with PA.

Methods

A cross-sectional survey design was employed to examine the real-world impact of PA in children, adolescents, and adults with PA, and caregivers of children with PA.

Results

Of 153 adult patients, 102 adolescents, and 382 caregivers of peanut-allergic children (n = 382), 6.8% and 24.8% of participants indicated being dissatisfied or somewhat dissatisfied, respectively, with current approaches to avoid or prevent PA reactions. Approximately two-thirds of patients and caregivers indicated that PA interferes at least somewhat with daily living. In terms of general HRQoL, adolescents, adult patients, and caregivers indicated that mental/psychosocial health was more problematic than physical health. PA patients and caregivers indicated worse HRQoL in all domains compared to healthy samples, and worse overall HRQoL, psychosocial, emotional, and social functioning than a sample of chronically ill patients. Results from the allergy-specific HRQoL measures showed that adolescents experienced greater impairment in overall HRQoL due to PA and in allergen avoidance and dietary restriction than adults.

Conclusion

PA negatively affects the general and PA-specific HRQoL of both patients and caregivers. The high emotional and psychosocial burden, in particular, demonstrates significant unmet need for patients with PA and their caregivers. Future work on treatment and preventive options to improve HRQoL for PA patients, particularly adolescents and their families, is needed.

Accuracy of component-resolved diagnostics in peanut allergy: Systematic literature review and meta-analysis

BACKGROUND

Peanut allergy diagnosis relies on clinical reactivity to peanut supported by detection of specific IgE (sIgE) antibodies. Extract-based sIgE tests have low specificity, so component-resolved diagnostics may complement whole-extract testing.

METHODS

We systematically collected peanut allergen component data in seven databases and studied the diagnostic accuracy of peanut storage proteins (Arah1, 2, 3) and cross-reactive peanut proteins (Arah8 PR-10 and Arah9 lipid transfer protein) through meta-analyses. The systematic literature review included studies employing peanut components and oral food challenge (OFC) as reference standard in patients suspected of peanut allergy. Data for component sIgE at pre-defined detection thresholds were extracted and combined in random-effects bivariate meta-analyses. Risk of bias was assessed as recommended by Cochrane, with two additional quality items of importance for this review.

RESULTS

Nineteen eligible studies presented data suitable for meta-analysis. In cross-sectional pediatric studies, the pooled sensitivity of Arah2-sIgE at 0.35 kU_A /L cutoff was 83.3% [95% CI 75.6, 88.9] and specificity in diagnosing objective peanut allergy was 83.6% [95% CI 77.4, 88.4]. Compared with 0.1 and 1.0 kU_A /L, this threshold provided the best diagnostic accuracy. At 0.35 kU_A /L, Arah1 and Arah3 had comparable specificity (86.0% and 88.0%, respectively) but significantly lower sensitivity compared with Arah2 (37.0% and 39.1%, respectively; P < .05).

CONCLUSION

sIgE to Arah2 can enhance the certainty of diagnosis and reduce the number of OFC necessary to rule out clinical peanut allergy in unclear cases.

Adverse events associated with peanut oral immunotherapy in children - a systematic review and meta-analysis

While peanut oral immunotherapy (POIT) represents a promising treatment for peanut allergies in children, safety concerns remain a common barrier to widespread adoption. We aimed to systematically assess available evidence to determine the risk and frequency of adverse events occurring during POIT, and examine study-level characteristics associated with their occurrence and severity. A systematic search of MEDLINE, EMBASE, and Web of Science was conducted through April 2019. Controlled and non-controlled studies evaluating POIT were eligible. Twenty-seven studies, involving 1488 subjects, were included. Adverse events to POIT were common and led to treatment discontinuation in 6.6% of children (95% CI 4.4–9.0; 27 studies, I² = 48.7%). Adverse events requiring treatment with epinephrine occurred among 7.6% (4.5–11.4; 26 studies, I² = 75.5%) of participants, at a rate of 2.0 per 10,000 doses (0.8–3.7; 15 studies, I² = 64.4). Use of a rush treatment phase and targeting a higher maintenance dose were associated with a higher risk and frequency of epinephrine use, while using co-treatments in addition to POIT was associated with a lower risk of treatment discontinuation due to adverse events. While adverse events to POIT are common, this study provides promising explorative evidence that certain modifications to existing treatment protocols could significantly improve treatment outcomes.

Commercial claims costs related to health care resource use associated with a diagnosis of peanut allergy

BACKGROUND

Peanut allergy (PA) affects approximately 1.6 million US children. The current standard of care is strict avoidance and prompt reaction treatment. Peanut allergy health care costs and health care resource utilization (HCRU) are poorly understood.

OBJECTIVE

To estimate PA health care costs and HCRU using a nationally representative commercial payer database.

METHODS

The IBM MarketScan Commercial Claims and Encounters Database was examined for PA diagnosis/reaction codes between January 2010 and October 2016 in patients 64 years of age or younger, with age cohort-matched controls. Outcomes were measured 12 months before and after the first claim date. Health care costs and HCRU were compared using Student's t tests and χ² tests.

RESULTS

Patients with a PA-related diagnostic code (n = 41,675) incurred almost double all-cause health care costs vs controls ($6436 vs $3493, P < .001), mainly from inpatient and outpatient medical costs ($5002 vs $2832, P < .001). More than one third of the PA group patients (36%) had a code indicative of an anaphylactic reaction during follow-up. Mean PA or reaction-related code costs per visit totaled $7921 for hospitalizations and $1115 for emergency department (ED) visits. Costs were 30% lower in patients with asthma codes without PA codes vs those with both codes ($5678 vs $8112, P < .001); all-cause ED costs were more than double in patients with atopic dermatitis codes with PA codes vs those without PA codes ($654 vs $308, P < .001).

CONCLUSION

National commercial payer claims data indicate a significant health care burden associated with a PA-related code, including over $6400/patient in annual all-cause costs and increased health care utilization.

A Quantitative Method for Detecting Ara h 2 by Generation and Utilization of Monoclonal Antibodies

Peanut (Arachis hypogaea) is one of the most common food allergens that can induce fatal anaphylaxis, and Ara h 2 is one of the major allergen components involved in peanut allergy. The aim of this study was to develop a quantitative method for detecting peanut allergen using monoclonal antibodies against Ara h 2. The splenocytes of immunized mice were fused with myeloma cells (SP2/0), and stable mAb-producing clones were obtained by limiting dilution. mAbs against Ara h 2 were isolated from mouse ascites, and specificity was confirmed by immunoblotting. Five mAbs with high purity and specific reactivity were obtained, which were referred to as 1-2E10, 2-1D5, 3-1C5, 4-1C2, and 5-1G4, respectively. After screening different mAb combinations for development of a sandwich ELISA, we selected 5-1G4 as the capture antibody and 1-2E10 as the detection antibody for the measurement of Ara h 2 from which an optimal correlation between the Ara h 2 concentration and the OD value was obtained. This sandwich ELISA could specifically detect Ara h 2 in peanut extract at concentrations as low as 5 ng/mL and up to 10 μg/mL. These mAbs can, therefore, serve as quantitative diagnostic reagents for peanut and peanut product risk assessment.

The role of environmental exposure to peanut in the development of clinical allergy to peanut

The prevalence of peanut allergy has increased over the years and still remains one of the most common causes of food-related anaphylaxis. The way in which peanut sensitization occurs has been explored, such as via maternal consumption in pregnancy, via breastmilk and through a disrupted skin barrier. It has previously been shown that environmental exposure to aeroallergens in household dust can be a risk factor for the development of allergic asthma. There is an increasing body of evidence that the combination of cutaneous sensitization via a disrupted skin barrier (ie children with eczema or with filaggrin mutations) and environmental peanut exposure influences the development of peanut allergy. This review aims to explore routes of peanut sensitization and the current evidence on how environmental exposure to peanut affects the development of peanut allergy.

Green, Yellow, and Red risk perception in everyday life - a communication tool

BACKGROUND

Adolescents have the highest risk for food allergy-related fatalities. Our main aim was to investigate the level of risk in everyday social situations as perceived by adolescents/young adults with peanut allergy, their families, and their friends.

METHODS

The web-based 'Colours Of Risks' (COR) questionnaire was completed by 70 patients (aged 12-23 years), 103 mothers and fathers, 31 siblings (aged 12-26 years), and 42 friends (aged 12-24 years). COR deals with six main contexts (home, school/university, work, visiting/social activities, special occasions/parties, and vacations), each with 1-12 items. Response categories are green (I feel safe), yellow (I feel uncertain), or red (I feel everything is risky).

RESULTS

There was a high level of agreement between participants in defining situations as safe, uncertain, or risky, but female patients and mothers rated fewer situations as safe compared to male patients and fathers. Being with close friends and family, and attending planned parties without alcohol were perceived as situations of low risk. While 94% of patients took an epinephrine auto-injector (EAI) into risky situations, only 65% took it into safe situations. In contrast to the close family, 31% of the friends did not know the patient had an EAI, and fewer knew how to administer the EAI.

CONCLUSION

Young adults with peanut allergy face challenges when moving from the safe home with ready assistance if needed, to independence with unpredictable surroundings and less certain help. Perceived 'safe' situations may in fact be the riskiest, as patients often do not take the EAI with them.

Conjunctival provocation test in diagnosis of peanut allergy in children

BACKGROUND

Peanut allergy frequently causes severe allergic reactions. Diagnosis includes detection of IgE to peanuts in serum or by skin prick tests. While children may have allergic sensitization without having clinical peanut allergy, oral peanut challenge is often required for accurate diagnosis. The conjunctival provocation test is used for diagnosis and evaluation of treatment effect in inhalant allergies, but it has not been evaluated as a tool for diagnosing peanut allergy.

OBJECTIVE

To investigate whether the conjunctival provocation tests may be feasible, accurate and safe in diagnosing clinically relevant peanut allergy in patients with suspected peanut allergy.

METHODS

This cross-sectional case-control study in children with clinical or laboratory suspected peanut allergy included 102 children recruited from the regional paediatric departments and specialist practices during one year from April 2011. A peanut-tolerant control group of 28 children of similar age was recruited locally. A double-blind placebo-controlled conjunctival provocation test with peanut extract was performed in all children, while oral peanut provocation was performed as double-blind placebo-controlled challenge in children with suspected peanut allergy and as an open challenge in the control children.

RESULTS

All 81 children with a positive double-blind placebo-controlled oral food challenge (OFC) also had a positive conjunctival provocation test. None of the children with negative conjunctival provocation test had a positive OFC. The sensitivity and the specificity of the conjunctival provocation test were 0.96 and 0.83, respectively. No children had severe adverse reaction caused by the conjunctival provocation test, whereas 23 children suffered an anaphylactic reaction to the OFC.

CONCLUSION AND CLINICAL RELEVANCE

Conjunctival allergen challenge appears to be feasible, accurate and safe in diagnosing children referred for suspected peanut allergy.

Mono-sensitisation to peanut component Ara h 6: a case series of five children and literature review

Here, we summarise the current clinical knowledge on Ara h 6 sensitisation and clinical relevance of this sensitisation pattern using five illustrative clinical cases. The literature search yielded a total of 166 papers, and an additional relevant article was found by 'snowballing'. A total of ten articles were considered relevant for this review. Most studies included patients with a sensitisation to Ara h 6 and cosensitisation to Ara h 2. Only three studies showed patients with a mono-sensitisation to Ara h 6. This illustrates that Ara h 6 mono-sensitisation has been neglected in literature. We present a case series of five children with sensitisation to peanut component Ara h 6. Only one of these five patients showed Ara h 8 cosensitivity. Three out of the five children had a positive double-blind placebo-controlled food challenge (DBPCFC), with moderate to strong reactions.

CONCLUSION

A mono-sensitisation to peanut component Ara h 6 is uncommon but can cause severe allergic reactions. Therefore, the determination of sIgE to Ara h 6 is warranted in patients with a suspected peanut allergy, especially in the absence of sensitisation to Ara h 1, 2, 3 and 9.

WHAT IS KNOWN

• Peanut allergy is common and can cause severe allergic reactions. • The diagnostics of peanut allergy has recently improved with the use of component resolved diagnosis What is new: • A mono-sensitisation to peanut component Ara h 6 is uncommon, but can cause severe allergic reactions • Determination of sIgE to Ara h 6 is warranted in patients with a suspected peanut allergy, especially in the absence of sensitisation to Ara h 1, 2, 3 and 9.

Advances in patent applications related to allergen immunotherapy

INTRODUCTION

Allergies are among the most prevalent chronic diseases worldwide. Allergen-specific immunotherapy is used as an alternative treatment to pharmacotherapy. These immunotherapies are performed with crude extracts, which have disadvantages when compared to the new approaches, among them are recombinant proteins and hypoallergens. This review aims to assess immunotherapy for allergies through patent application analysis spanning recent decades.

AREAS COVERED

Patents referring to allergen immunotherapies used in allergy treatment. Data were obtained from the Espacenet® website, using the Cooperative Patent Classification (CPC) system. Two-hundred-and-one patent applications were analyzed, taking into consideration their classification by the type of technology and applicant.

EXPERT OPINION

Allergen-specific immunotherapy represents the only potentially curative therapeutic intervention for the treatment of allergic diseases. The extract-based immunotherapy is being replaced by the use of recombinant allergens, highlighting the hypoallergenic forms, which have low IgE-binding while retaining T-cell reactivity. It is expected that the development of hypoallergens will expand the scope of allergen-specific immunotherapy, especially if associated with alternative systems for expression and delivery systems with future potential. Furthermore, these new developments will likely address the problem of long-term protocols in allergen-specific immunotherapy, thus allowing better patient adherence and compliance.