A shift in peanut allergy management

Peanut allergy affects approximately 2% of people in the U.S. and is the leading cause of fatal and near-fatal allergic reactions. While the risk of fatality is low (about 1 in 10 million), the potential for developing severe reactions and anaphylaxis is high. The allergy self-resolves in about 20% of people, and this usually happens during early childhood. For most, however, peanut allergy is a lifelong illness. A team of allergists recently published a review in JAMA Network of the major developments in peanut allergy management over the last decade.

“We are highlighting a significant health concern, and we’re going into major shifts that have occurred in how we manage peanut allergies nowadays compared to the past,” said Dr. Aikaterini Anagnostou, professor of pediatrics – allergy and immunology at Baylor College of Medicine and Texas Children’s Hospital and lead author of the review. “All these shifts have helped us improve the management of peanut allergy by first reducing the risk of developing the allergy, as well as treating it appropriately.”

The National Institute of Allergy and Infectious Diseases recommends introducing peanuts during infancy, typically in the first 4-6 months of life, when an infant is ready for solid food. This recommendation was the result of a clinical trial that proved early introduction reduces the risk of developing a peanut allergy. In the past, it was recommended to wait until the child was 2 or 3 years old, originally due to fear of choking on nuts. Now, children under 2-3 years can consume peanuts in the form of peanut butter to avoid choking hazards. The incidence of peanut allergy appears to be decreasing due to early introduction.

The approach in treatment for those who have developed peanut allergy also has shifted.

“In the past, all we could offer was peanut avoidance. If someone had peanut allergy, we would tell them to avoid peanuts for the rest of their lives and gave them emergency medication called epinephrine to carry with them to treat severe reactions,” Anagnostou said.

Epinephrine always came in the form of injection, but it also now comes in nasal form, which is helpful for parents that are reluctant to give their child an injection in an emergency.

More active options exist today to treat peanut allergy, including immunotherapy and using a biologic called omalizumab. Today’s therapies help increase the threshold for peanut allergy through a process called desensitization, allowing the patient to tolerate more peanut before developing allergic reactions. This increase in threshold provides protection from accidental exposures.

“This is important because you might be accidentally exposed to peanuts, and if your threshold is low, you have a reaction, but with this therapy, if you increase your threshold, then you’re less at risk for problems,” Anagnostou said.

Both oral immunotherapy (OIT) and biologic therapy  (omalizumab) increase the threshold of the reactivity of peanuts. While these treatments increase the threshold, they do not cure the allergy.

If individuals are interested in pursuing therapy for their peanut allergy or other food allergies, they should connect with an allergist to discuss their options.

Co-authors include Dr. Helen Brough and Dr. Elissa Abrams.

By Homa Warren