Peanut Allergies Unshelled: New Treatment and Preventive Measures
By Roshni Printer
Have you ever felt the craving for a warm peanut butter and condensed milk toast?
While most of us can probably relate, peanut allergy is one of the most common food allergies. It typically develops in early childhood and persist in around 80% of patients for life [1, 2]. In severe cases, life-threatening symptoms can occur after ingestion of even a small trace of peanut. The presence of these traces in everyday meals makes it challenging to avoid accidental ingestion. In the past, “treatment” of peanut allergy was largely limited to complete avoidance. However, recent studies have brought forward ways to prevent as well as manage this common condition: Let’s delve into them and crack the peanut allergy!
In 2015, a landmark clinical trial published in the New England Journal of Medicine suggested that the introduction of peanuts in the diets of infants at risk could prevent the development of peanut allergy [3]. The mechanism is called desensitization: a treatment to increase the body’s tolerance to peanuts by exposing the infant to an increasing amount of peanut antigen, the allergy-causing component in peanuts. Termed “oral immunotherapy,” desensitization can modify the developing immune system of infants so that peanuts can be recognized by the body as a safe food instead of a threat.
In May 2017, after taking recent evidence into consideration, the United States National Institute of Allergy and Infectious Diseases (NIAID) recommended early introduction of peanuts to infants at risk, especially to those aged four to six months with severe eczema and/or egg allergy [4]. Preliminary immunological test should be conducted to infants with severe eczema and/or egg allergy to ensure safety and to determine the preferred method of the administration of dietary peanut. However, their recommendation for infants who had already been identified as allergic was avoidance.
In 2023, further data from a new study urged the promotion of this preventive intervention to the general population [5]. Compared to the marginal reduction of 4.6% by targeting only the highest-risk infants with severe eczema, extending the scope to all infants could lower the prevalence by 77%. The study also showed that the older a child grows, the less effective the intervention would become. This could explain the ten-fold lower rate of peanut allergy in the children in Israel, where peanut is frequently fed to infants in large quantities as snacks, when compared to the UK [6]. This prompted the National Health Service (NHS) of the UK to recommend introducing crushed or ground peanuts, or peanut butter to infants from the age of six months, after the infant is ready to ingest solid foods [7, 8].
The breakthroughs in the study of peanut allergy also came with the development of Palforzia, a novel drug for young patients already diagnosed with peanut allergy. Targeting patients aged from four to 17 years old, this drug was approved by the US Food and Drug Administration (FDA) in January 2020 [9]. Itcontains peanut allergens in powder form which can be ingested with a soft food [10]. By gradually escalating the dose until a limit is found, the patient can build up tolerance to small amounts of peanut protein. After the up-dosing stage, the patient will need to take a maintenance dose every day for the treatment to remain effective. This fact, combined with the high cost and the requirement of biweekly visits to doctors in the first six months of the treatment discouraged the widespread use by patients, especially during the pandemic shortly after its launch. These limitations eventually led to Palforzia’s flop in sales – showing us how a medical breakthrough does not necessarily lead to a successful business [10, 11]!
The study of peanut allergy highlights the tentative nature of science – scientific theories are subject to change when new evidence arises. Therefore, it is crucial to be open-minded and keep abreast of the latest developments in scientific research. Before you share this article to those with peanut allergy, please make sure they understand that any attempt on the new therapeutic strategies should be closely supervised by medical professionals.
References
[1] Whitsel, R. M, Bjelac, J. A., Subramanian, A., Hoyt, A. E. W., & Hong, S. J. (2021). Cleveland Clinic Journal of Medicine, 88(2), 104–109. https://doi.org/10.3949/ccjm.88a.20130
[2] Al-Ahmed, N., Alsowaidi, S., & Vadas, P. (2008). Allergy, Asthma & Clinical Immunology, 4(4), 139–143. https://doi.org/10.1186/1710-1492-4-4-139
[3] Du Toit, G., Roberts, G., Sayre, P. H., Bahnson, H. T., Radulovic, S., Santos, A. F., Brough, H. A., Phippard, D., Basting, M., Feeney, M., Turcanu, V., Sever, M. L., Gomez Lorenzo, M., Plaut, M., Lack, G., & LEAP Study Team (2015). Randomized trial of peanut consumption in infants at risk for peanut allergy. The New England Journal of Medicine, 372(9), 803–813. https://doi.org/10.1056/NEJMoa1414850
[4] Togias, A., Cooper, S. F., Acebal, M. L., Assa'ad, A., Baker, J. R., Jr., Beck, L. A., Block, J., Byrd-Bredbenner, C., Chan, E. S., Eichenfield, L. F., Fleischer, D. M., Fuchs, G. J., III, Furuta, G. T., Greenhawt, M. J., Gupta, R. S., Habich, M., Jones, S. M., Keaton, K., Muraro, A., … Boyce, J. A. (2017). 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. Journal of allergy and clinical immunology, 139(1), 29–44. https://doi.org/10.1016/j.jaci.2016.10.010
[5] Roberts, G., Bahnson, H. T., Du Toit, G., O'Rourke, C., Sever, M. L., Brittain, E., Plaut, M., & Lack, G. (2023). Defining the window of opportunity and target populations to prevent peanut allergy. Journal of Allergy and Clinical Immunology, 151(5), 1329–1336. https://doi.org/10.1016/j.jaci.2022.09.042
[6] Du Toit, G., Katz, Y., Sasieni, P., Mesher, D., Maleki, S. J., Fisher, H. R., Fox, A. T., Turcanu, V., Amir, T., Zadik-Mnuhin, G., Cohen, A., Livne, I., & Lack, G. (2008). Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. Journal of Allergy and Clinical Immunology, 122(5), 984–991. https://doi.org/10.1016/j.jaci.2008.08.039
[7] Gallagher, J. (2023, March 17). Give babies peanut butter to cut allergy by 77%, study says. BBC News. https://www.bbc.com/news/health-64987074
[8] National Health Service. (2021, November 5). Food allergies in babies and young children. https://www.nhs.uk/conditions/baby/weaning-and-feeding/food-allergies-in-babies-and-young-children/
[9] U.S. Food and Drug Administration. (2020, January 31). FDA approves first drug for treatment of peanut allergy for children. https://www.fda.gov/news-events/press-announcements/fda-approves-first-drug-treatment-peanut-allergy-children
[10] Aimmune Therapeutics. (2022). Palforzia Treatment Handbook. https://www.palforzia.com/sites/default/files/2022-10/treatment_handbook.pdf
[11] Halpert, W. (2022, December 3). Peanut allergies: Parents worry after Palforzia drug sales flop. BBC News. https://www.bbc.com/news/world-us-canada-63788730
[12] Speed, M. (2023, September 4). Nestlé sells peanut allergy business after insufficient demand. Financial Times. https://www.ft.com/content/436756c9-80c5-499a-bddf-e7f56defe844