A new treatment for peanut allergy appears to allow children who are severely allergic to consume a small amount of peanut — potentially protecting them from having a reaction if they accidentally eat some.
According to a clinical trial of about 500 children aged four to 17 published in the New England Journal of Medicine, about 76 per cent of children, who were initially only able to eat about half a peanut without a severe reaction, were able to eat the equivalent of one whole peanut after completing the immunotherapy treatment.
Two-thirds of children were able to eat the equivalent of two peanuts.
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“What we demonstrated is that it had the effect of decreasing the frequency and severity of allergic reactions,” said Dr. Dan Adelman, lead study author and chief medical officer of Aimmune, the company which conducted the research.
This treatment is not a cure. Even after completing the 24-week procedure, patients need to keep taking a daily dose of peanut protein for a yet-to-be-determined amount of time to keep up their resistance — possibly forever. Children also can’t suddenly go eat a peanut butter sandwich.
“We’re still telling them to avoid peanut,” Adelman said. “This is not a treatment in order to allow the free-range consumption of peanut.”
“It’s intended to protect patients from the adverse consequences of an accidental exposure to peanut.”
Oral immunotherapy treatment
Oral immunotherapy is already being used to treat peanut allergies. Dr. Harold Kim, president of the Canadian Society of Allergy and Clinical Immunology, estimates that it’s currently being performed at around seven sites in Canada, mostly by allergists associated with universities.
At his Western University clinic, staff measure out a tiny amount of peanut flour and put it into a capsule. Under medical supervision, the patient opens the capsule and mixes it into a food, like yogurt, and eats it. If they don’t react, they’re then sent home with pre-measured doses of peanut to eat every day.
After about a month, they come back to the clinic and try a higher dose. After about a year of eating a gradually-increasing dose, they’re able to eat the equivalent of about a single peanut without issue, he said.
What’s different about Aimmune’s treatment is that the capsules or packets of peanut protein are produced and pre-measured in a pharmaceutical facility and come with a defined dosage procedure. Clinical guidelines for oral immunotherapy don’t currently exist in Canada.
Adelman calls the current approach “homebrew.”
“The difference between it and a regulated pharmaceutical product is that we know that every single dose that is administered, we know exactly how much we’re giving.” Patients receive it according to a clinically-tested regimen, too, Adelman said.
Kim agrees, saying that the procedure should be more accurate and less risky than current methods.
He also thinks that a pharmaceutical immunology product might make the treatment more widely available. “Many allergists are waiting for a commercially available product with a protocol that’s been cleared by the government and Health Canada to start doing this.”
“A lot of patients with peanut allergy really want this treatment. They’ve been waiting for this treatment.”
Risks and drawbacks
Oral immunotherapy is not for everyone, though, according to Jennifer Gerdts, executive director of patient advocacy group Food Allergy Canada.
“You have to be very willing to invest in making this part of your daily routine,” she said, as you need to keep taking your daily peanut dose to stay immune, still avoid peanuts, and continue to carry epinephrine in case of an allergic reaction. This can still be a burden, she added, and you have to be aware of it.
In the Aimmune trial, 99 per cent of the participants who took the drug had some kind of adverse event during the intervention period — only a little more than the 95 per cent of patients who were taking a placebo and still had some kind of reaction.
These were mostly mild or moderate and included gastrointestinal and respiratory problems. Nearly six per cent of participants had a severe adverse event, and nearly 12 per cent of people taking the drug withdrew from the trial.
Adelman said these rates of adverse events are very consistent with other allergy therapies and that during the trial, people were specifically prohibited from using antihistamines, which they might do in a regular clinical setting.
Another issue may be cost. Aimmune plans to apply for FDA approval for its medication by the end of the year, and to European and Canadian authorities around the middle of 2019. It will then sell its product, which will cost more than the peanut flour currently being used by doctors.
Adelman feels it’s worth it for the pharmaceutical-grade capsule. “I would say it is not an equivalent product.”
Some people find completely avoiding a food very stressful, Gerdts said.
“If you were to sit down at a Thanksgiving buffet, for those without a food allergy, that looks like a great celebration of family and friends and great food,” she said. “For the person with food allergy, they’re looking at that and going, ok, what’s safe?”
Although she cautions that immunotherapy isn’t appropriate for everyone, for people who find avoiding peanuts is too much, it might be a good option.
Kim calls the trial “exciting news.”
“If you think about the state of food allergy seven years ago, I think most of us would have thought that this was literally a dream.”