Peanut oral immunotherapy is a treatment for peanut allergy in infants and young children, aiming to protect them from severe reactions due to accidental peanut exposure. Current protocols typically involve initial dose escalation below the reaction threshold. However, some patients have higher reaction thresholds or might not have an active peanut allergy, especially since oral food challenges aren’t always performed before starting OIT.
Conducted by researchers at the University of Michigan and appearing in the May issue of the Journal of Allergy and Clinical Immunology: Global, this single-center study aimed to determine how many low-risk patients under four years old, previously diagnosed with peanut allergy, could tolerate a full peanut oral food challenge during an accelerated initial dose escalation as part of their OIT initiation.
Of the 76 patients in the peanut OIT program, 19 were identified as low-risk candidates for an accelerated initial dose escalation based on specific criteria: a history of allergic reaction to peanuts without anaphylaxis, a small wheal diameter (less than 8mm) on a skin prick test, and a peanut serum immunoglobulin E level below 5 kU/L.
Of these 19 low-risk candidates, 16 children, with a mean age of 20.3 months, participated in the accelerated dose escalation program. The parents of the remaining three children chose not to participate due to perceived risks.
The results indicated that 11 of the 16 children (68.8%) successfully tolerated the full dose of peanut — demonstrating a resolution of their peanut allergy — before initiating the accelerated dose escalation. The other five children experienced mild reactions during the escalation, such as rash, localized hives, or rhinorrhea (runny nose). Even for these children, the accelerated approach proved beneficial, as they started OIT at a significantly higher mean dose (450mg versus 25mg of peanut protein) and reached maintenance dosing with fewer clinic visits — an average of 4.5 fewer — compared to those on a standard OIT protocol.
Based on these findings, the authors conclude that children with low-risk peanut allergies, as defined by their age, clinical history, and allergy test results, should be offered a peanut oral food challenge before starting oral immunotherapy. This is because the majority of them are likely to tolerate peanuts without requiring extensive treatment.
It’s important to note that this study had limitations, primarily a small cohort with limited racial and ethnic diversity. Therefore, further research is necessary to confirm the safety and generalizability of this accelerated approach.
