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peanut allergy

Etiology: - eating peanuts or peanut products [23] - risk factors for peanut allergy [3] - infant formulas containing soy - infant exposure to peanut oil containing creams * skin contact with peanuts produces local reaction or none at all [23] * proximity to someone consuming peanuts not a risk [23] Epidemiology: 1) one of the most common & severe food allergies - prevalence is 1.3-1.6% (0.6-1.2% in children) [5] 2) 10% of people allergic to peanuts are also allergic to soy 3) many children with asthma have peanut allergy but do not know it [12] Pathology: - allergy is mediated by antigen-specific IgE Clinical manifestations: - see food allergy Laboratory: - peanut IgE Ab in serum [16] Special laboratory: - peanut allergen skin testing [16] - wheal diameter <2 mm: child may try peanut at home - wheal diameter 3-7 mm: peanut should be administered by a supervised feeding or graded challenge - wheal diameter >= 8 mm: child is likely allergic, should avoid peanut & be managed by a specialist Management: 1) antihistamines 2) steroids 3) epinephrine* 4) activated charcoal may interfere with absorption of antihistamines & steroids [4] 5) monoclonal antibody to IgE may be useful [2] for prophylaxis 6) oral immunotherapy (development of tolerance) a) oral immunotherapy consisting of incrementally increasing oral doses of peanut [7,9,20] - procedure: - hospitalized children spent a day swallowing small but increasing doses of a specially prepared peanut flour, until they had a reaction - the child was sent home with a daily dose just under the reactive amount, generally ~ 1/1000 of a peanut - after 8-10 months of gradual dose increases, most chilren can eat the peanut-flour equivalent of 15 peanuts daily - oral immunotherapy may be less effective in adults than in children & adolescents [20] - complications: increased risk for anaphylaxis* (RR=3.1) [21] b) introduction of peanuts into the diet from age 4-11 months through 5 years of age decreases development of peanut allergy in high-risk infants [11,13,14] c) combined probiotic (Lactobacillus rhamnosus) & peanut oral immunotherapy daily for 18 months associated with peanut tolerance in allergic children at 3 & 12 months & at least 4 years after treatment [17] d) Hello Peanut 1st food item with FDA-backed claim that it may prevent development of peanut allergy e) discontinuing or lowering the dose of oral immunotherapy may lead to resensitization [22] 7) epicutaneous immunotherapy - patch containing 100 or 250 micrograms peanut protein changed daily [15] - 46-48% of patients able to ingest >= 10 times the peanut protein he or she could at baseline [15] - appears to increase peanut tolerance, but only in children [19] * patients with history of anaphylaxis to peanuts should carry epinephrine kit or Epipen * epinephrine should be administered at the first sign that something is wrong while eating (see anaphylaxis) [23] Prevention: - early introduction of peanut-containing foods at - 4 to 6 months for infants with severe eczema, egg allergy, or both - 6 months for infants with only mild-to-moderate eczema - infants without eczema or any food allergy should eat solid foods containing peanuts in accordance with family preferences & cultural practices [16] Notes: - patients should avoid food with cumin powder or ground cumin - some products containing cumin have tested positive for undeclared peanut protein [10] - all low-risk infants can start peanut around age 6 months [16] - infants with severe eczema or egg allergy should be evaluated with skin testing by a specialist - peanut IgE Ab in serum may be ordered if no specialist is readily available [16]

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References

  1. Prescriber's Letter 10(3):13 2003
  2. Journal Watch 23(8):66, 2003 Leung DYM et al, Effect of anti-IgE therapy in patients with peanut allergy. N Engl J Med 348:986, 2003 PMID: 12637608
  3. Journal Watch 23(8):66-67, 2003 Lack G et al, Factors associated with the development of peanut allergy in childhood. N Engl J Med 348:977, 2003 PMID: 12637607
  4. Prescriber's Letter 10(8):45 2003
  5. Journal Watch 24(3):26-27, 2004 Kagan RS et al, Prevalence of peanut allergy in primary-school children in Montreal, Canada. J Allergy Clin Immunol 112:1223, 2003 PMID: 14657887 - Kagan RS et al http://www2.us.elsevierhealth.com/scripts/om.dll/serve?retrieve=pii/S0091674903023637 - Sicherer SH et al Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: a 5-year follow-up study. J Allergy Clin Immunol 112:1203, 2003 PMID: 14657884 http://www2.us.elsevierhealth.com/scripts/om.dll/serve?retrieve=pii/S0091674903020268
  6. Al-Muhsen S et al, Peanut allergy: an overview. CMAJ 168:1279, 2003 (review) PMID: 12743075
  7. AAAAI meeting abstracts, #576 & #665, 2009 http://www.aaaai.org/media/newsroom/am2009/JACI%20Feb%202009%20Abstract%20Supplement.pdf Associated Press, March 2009
  8. Prescriber's Letter 16(6): 2009 Drug Therapy Considerations for Patients with Peanut Allergy Detail-Document#: 250608 (subscription needed) http://www.prescribersletter.com
  9. Anagnostou K et al Assessing the efficacy of oral immunotherapy for the desensitisation of peanut allergy in children (STOP II): a phase 2 randomised controlled trial. The Lancet, Early Online Publication, 30 January 2014 PMID: 24485709 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2962301-6/abstract
  10. FDA Safety Alert. Feb 19, 2015 FDA Consumer Advice on Products Containing Ground Cumin with Undeclared Peanuts. http://www.fda.gov/Food/RecallsOutbreaksEmergencies/SafetyAlertsAdvisories/ucm434274.htm
  11. Du Toit G et al Randomized Trial of Peanut Consumption in Infants at Risk for Peanut Allergy. N Engl J Med. February 23, 2015 PMID: 25705822 http://www.nejm.org/doi/full/10.1056/NEJMoa1414850 - Gruchalla RS, Sampson HA Preventing Peanut Allergy through Early Consumption - Ready for Prime Time? N Engl J Med. February 23, 2015 PMID: 25705823 http://www.nejm.org/doi/full/10.1056/NEJMe1500186
  12. American Thoracic Society. Public Release. May 17, 2015 Many children with asthma have reaction to peanuts, but do not know it. http://www.eurekalert.org/pub_releases/2015-05/ats-mcw050515.php
  13. Du Toit G, Sayre PH, Roberts G et al Effect of Avoidance on Peanut Allergy after Early Peanut Consumption. N Engl J Med. March 4, 2016 PMID: 26942922 http://www.nejm.org/doi/10.1056/NEJMoa1514209
  14. Ierodiakonou D et al Timing of Allergenic Food Introduction to the Infant Diet and Risk of Allergic or Autoimmune DiseaseA Systematic Review and Meta-analysis. JAMA. September 20, 2016 PMID: 27654604 http://jama.jamanetwork.com/article.aspx?articleid=2553447
  15. Jones SM, Sicherer SH, Burks AW et al Epicutaneous immunotherapy for the treatment of peanut allergy in children and young adults. Journal of Allergy & Clinical Immunology. Oct 27, 2016 PMID: 28091362 http://www.jacionline.org/article/S0091-6749(16)30966-6/fulltext - National Institutes of Health Skin patch to treat peanut allergy shows benefit in children. News Release. Oct 26, 2016 https://www.nih.gov/news-events/news-releases/skin-patch-treat-peanut-allergy-shows-benefit-children
  16. Togias A, Cooper SF, Acebal ML et al Addendum guidelines for the prevention of peanut allergy in the United States: Report of the National Institute of Allergy and Infectious Diseases-sponsored expert panel. J Allergy Clin Immunol. 2016 139:29-44 PMID: 28065278 http://www.jacionline.org/article/S0091-6749(16)31222-2/fulltext - National Institute of Allergy and Infectious Diseases. Addendum Guidelines for the Prevention of Peanut Allergy in the United States. Summary for Clinicians. Jan 2017 https://www.niaid.nih.gov/sites/default/files/peanut-allergy-prevention-guidelines-clinician-summary.pdf
  17. Hsiao KC, Ponsonby AL, Axelrad C et al Long-term clinical and immunological effects of probiotic and peanut oral immunotherapy after treatment cessation: 4-year follow-up of a randomised, double-blind, placebo-controlled trial. Lancet Child & Adolescent Health. Aug 15, 2017 Not indexed in PubMed http://thelancet.com/journals/lanchi/article/PIIS2352-4642(17)30041-X/fulltext - Greenhawt MJ Probiotic and peanut oral immunotherapy: a breakthrough for allergy treatment. Lancet Child & Adolescent Health. Aug 15, 2017 Not indexed in PubMed http://thelancet.com/journals/lanchi/article/PIIS2352-4642(17)30042-1/fulltext - Dunn Galvin A, McMahon S, Ponsonby AL et al The longitudinal impact of probiotic and peanut oral immunotherapy on health-related quality of life. Allergy. 2017 Oct 20. [Epub ahead of print] PMID: 29052245
  18. FDA Statement. September 7, 2017 Statement from FDA Commissioner Scott Gottlieb, M.D., on a new qualified health claim advising that early introduction of peanuts to certain high-risk infants may reduce risk of peanut allergy https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm575008.htm
  19. Sampson HA, Shreffler WG, Yang WH,et al. Effect of varying doses of epicutaneous immunotherapy vs placebo on reaction to peanut protein exposure among patients with peanut sensitivity: A randomized clinical trial. JAMA 2017 Nov 14 PMID: 29136445 https://jamanetwork.com/journals/jama/article-abstract/2662891
  20. The PALISADE Group of Clinical Investigators AR101 Oral Immunotherapy for Peanut Allergy. N Engl J Med. Nov 18, 2018 PMID: 30449234 https://www.nejm.org/doi/full/10.1056/NEJMoa1812856 - Perkin MR. Oral Desensitization to Peanuts. N Engl J Med. Nov 18, 2018 PMID: 30449233 https://www.nejm.org/doi/full/10.1056/NEJMe1813314
  21. Chu DK, Wood RA, French S et al Oral immunotherapy for peanut allergy (PACE): a systematic review and meta-analysis of efficacy and safety. The Lancet. April 25, 2019 PMID: 31030987 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30420-9/fulltext - Roberts G, Angier E. Peanut oral immunotherapy: balancing benefits and risks for individuals. The Lancet. April 25, 2019 PMID: 31036338 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)30767-6/fulltext
  22. Chinthrajah RS, Purington N, Andorf S et al Sustained outcomes in oral immunotherapy for peanut allergy (POISED study): a large, randomised, double-blind, placebo- controlled, phase 2 study. Lancet Sept 12, 2019 PMID: 31522849 https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)31793-3/fulltext
  23. NEJM Knowledge+ Allergy/Immunology - Greenhawt M. Environmental exposure to peanut and the risk of an allergic reaction. Ann Allergy Asthma Immunol. 2018 May;120(5):476-481.e3. PMID: 29555352 Review. - Capucilli P, Wang KY, Spergel JM. Food reactions during avoidance: Focus on peanut. Ann Allergy Asthma Immunol. 2020 May;124(5):459-465. PMID: 32001367 Review.