Anaphylaxis During Peanut OIT Has Multiple Preventable Causes - Medscape

Various triggers tin origin anaphylaxis during peanut oral immunotherapy (POIT), but they're preventable, a small retrospective study suggests.

"Anaphylaxis episodes during POIT tin hap some during dose escalation and attraction phases," Aikaterini Anagnostou, MD, PhD, and her co-authors astatine Baylor College of Medicine successful Houston, Texas, constitute successful a Letter to the Editor published this period successful Pediatric Allergy and Immunology.

"In our real-world cohort…anaphylaxis was often the effect of antecedently reported avoidable triggers," they add. "Patients indispensable beryllium educated connected these successful an effort to forestall adverse outcomes."

New, Effective Therapy With Unknown Long-Term Risks

Since the US Food and Drug Administration approved Peanut (Arachis hypogaea) Allergen Powder-dnfp (Palforzia) successful 2020, POIT has been helping peanut-allergic patients debar anaphylaxis, but not overmuch is yet known astir anaphylaxis hazard during semipermanent therapy.  

To code this cognition gap, analyse anaphylaxis episodes during dose escalation and maintenance, and place imaginable hazard factors and avoidable triggers, Anagnostou and her colleagues reviewed the records of anaphylaxis episodes successful 75 patients aged 3-17 years who completed POIT astatine 1 world probe halfway betwixt 2017 and 2021.

All patients started astatine 2 mg of peanut macromolecule (pp) and gradually accrued their monthly intake to a attraction dose of 300 mg pp astatine astir 9 months. At that point, 15 patients chose to summation their doses to 450-900 mg per month, and 3 opted to enactment astatine 150 mg. Monthly attraction follow-up ranged from 8-42 months.

Study findings amusement that, overall, 17% of patients experienced anaphylaxis episodes: 53% during dose escalation, 47% during maintenance, and nary anaphylaxis reported aft 16 months of treatment.

Anaphylactic reactions were much apt successful older patients and successful those with higher baseline peanut-specific immunoglobulin E (IgE) and Ara h2 (the strongest predictor of peanut allergy).

Tiffany Owens, MD, adjunct prof of allergy and immunology astatine The Ohio State University Wexner Medical Center successful Columbus, said by email that, with POIT being a caller treatment, clinicians are gathering and sharing information to assistance them fine-tune their diligent management.

"An important item of this survey is that the likelihood for anaphylaxis accrued with age," noted Owens, who was not progressive with this research. "Additional studies volition beryllium needed to find if older individuals are candidates for POIT, oregon if this is simply a amended therapy for younger food-allergic children."

The findings item important triggers, including exercise, viral illness, dosing connected an bare stomach, blistery ablution soon aft dosing, and accidental peanut exposure.

Safe for Most, but Monitoring and More Research Needed

Providers request to amended patients connected avoiding hazard factors and managing risk, Antonella Cianferoni, MD, PhD, subordinate prof of pediatrics specializing successful allergy and immunology astatine Children's Hospital of Philadelphia, told Medscape Medical News by email.

"Food allergy affects betwixt 5% and 8% of children, and each forms of allergy immunotherapy, including POIT, are associated with a tiny hazard for anaphylaxis," Cianferoni, who was not progressive successful the study, said. "Peanut and different nutrient allergies are lifelong, and life-threatening reactions are unpredictable."

"This survey confirms that, portion nutrient immunotherapy requires education, vigilance, and availability of epinephrine, it is wide harmless and good tolerated by astir patients," she added.

Rachel G. Robison, MD, subordinate prof of pediatrics specializing successful allergy and immunology astatine Vanderbilt University Medical Center successful Nashville, Tennessee, noted that different studies enactment the thought that higher baseline peanut-specific IgE is linked with accrued reactions to POIT.

"Notably, though immoderate patients were followed up to 42 months, nary systemic reactions occurred beyond 16 months," Robison, who besides was not associated with the study, said by email. "Following a larger colonisation semipermanent whitethorn springiness amended penetration arsenic to whether these reactions genuinely lessen implicit time.

"Increased property being associated with much systemic reactions deserves much study," she added.

Edwin H. Kim, MD, manager of the UNC Food Allergy Initiative astatine the University of North Carolina School of Medicine astatine Chapel Hill, said that these results are "a reminder that we request to support our defender up astatine each times during treatment." Kim was not a portion of this probe team.

While the benefits of POIT are clear, patients and their providers request to equilibrium the benefits with the risks, helium said by email.

"POIT, with its beardown desensitization potential, tin beryllium a fantastic therapy for peanut allergy; however, the hazard that comes with it whitethorn not marque it the champion medicine for each peanut-allergic patient," Kim advised.

"For those who mightiness conflict to debar triggers, peanut oral immunotherapy mightiness not beryllium the champion therapy, and waiting for alternate therapies mightiness beryllium the amended choice."

Funding accusation was not provided. Anagnostou reports applicable fiscal relationships with DBV Technologies and Aimmune Therapeutics. Robison reports applicable fiscal relationships with Aimunne Therapeutics. Two co-authors, arsenic good arsenic Cianferoni, Owens, and Kim, study nary applicable fiscal relationships.

Pediatr Allergy Immunol. Published online December 4, 2022. Letter to the Editor

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