Experts discuss implementing food allergy therapy into practice
HOUSTON — Food allergies affect 6% to 8% of children and 2% to 3% of adults, according to a presentation at the American College of Asthma, Allergy & Immunology Scientific Meeting.
Peanut allergy, affecting 2.2% of children and 1.8% of adults, is the leading cause of food-induced ED visits and mortality from anaphylaxis, Edwin H. Kim, MD, MS, FACAAI, of the University of North Carolina at Chapel Hill, explained during the presentation.
While avoiding allergens and acute treatment are the primary management methods for food allergies, even the most vigilant patients can still have an anaphylactic reaction that could potentially lead to death.
Food allergy therapies have emerged as an effective treatment for some patients, despite some controversies stemming from adverse reactions to treatment.
Safety of immunotherapy
Jonathan Hourihane, MD, professor of pediatrics and child health at the Royal College of Surgeons of Ireland, Dublin, discussed two emerging immunotherapies for peanut allergy that have shown promise, but with mixed reactions from clinicians.
For instance, patients in the PALISADE trial, which tested the biologic oral immunotherapy AR101, had effective responses to therapy, but still experienced adverse reactions.
Within the study, 38% of patients taking AR101 had no reaction, while 32% had mild reactions, 25% had moderate reactions, and 5% had severe or worse reactions. However, just 2% of patients taking placebo had no reaction, 28% had a mild reaction, 59% had a moderate reaction, and 11% had a severe or worse reaction.
Outcomes and documentation of immunotherapy
Aikaterini Anagnostou , MD, PhD, FACAAI, an associate professor at Texas Children’s Hospital, explained during the presentation that the most important aspects of shared decision-making for peanut oral immunotherapy are the primary clinicians’ role in diagnosing the patient, discussing treatment options, and coaching the patient/family to participate in making treatment decision.
Previous studies showed that families seeking peanut oral immunotherapy had raised concerns about the daily doses and consequences to missing doses, the time immunotherapy will take, and the 2-hour limit placed on their child’s exercise.
“We have a patient in front of us that is going to embark on a journey alongside us and with our help,” Anagnostou said. “We have to involve them from the very beginning, understand where they’re coming from, what they’re hoping to achieve through this treatment and how we can help them along the way.”
Implementing food allergy therapy in practice
Douglas P. Mack, MSc, MD, an assistant clinical professor at McMaster University, explained that “For years, what we’ve been doing is just telling families ‘diagnose and adios,’ you have a food allergy, here’s your EpiPen and we’ll see you in 2 or 3 years for reassessment.”
Now, with oral immunotherapy, patients are encouraged to engage in therapy that could potentially lead to adverse reactions both at homeand in a clinical setting. Therefore, patients enrolled in the therapy and their families require extensive education to understand the treatment itself and the risks involved.
Although many families do not have a background in health care, physicians must train them as though they do, in order to give them the skills to assess the appropriate dose, determine if their child is having a reactions and the timing and type of treatment.
Mack explained that challenges of implementing food allergy therapy include patient reactions to therapies, illnesses causing patients to cancel visits, long observation times, and patient demand.
Optimal candidates for food allergy therapy
Warner W. Carr , MD, FACP, FACAAI, associate medical director of Southern California Research at Allergy and Asthma Associates of Southern California Medical Group, explained during the presentation that the ideal patient has a clear history of reactions, and has clear skin prick testing and serum testing results.
For those with conflicting results on skin prick testing and serum testing, Carr recommended an oral food challenge to determine the extent of a patient’s reaction and whether they would be a good candidate for therapy.
Before recommending oral immunotherapy, physicians should ensure asthma and atopic dermatitis is well-controlled in patients with the conditions.
Carr explained that conditions that are contradictory to oral immunotherapy include eosinophilic esophagitis, uncontrolled asthma, and uncontrolled irritable bowel syndrome or inflammatory bowel disease. – by Erin Michael
Kim EH, et al. Implementing Food Allergy Therapy in Clinical Practice. Presented at: American College of Asthma, Allergy & Immunology Scientific Meeting; Nov. 7-11, 2019; Houston.
Disclosures: Anagnostou reports being a clinical investigator and contracted research at Aimmune Therapeutics, Inc. Carr reports being on the advisory committee/honorarium from Aimmune Therapeutics, Inc., DBV Technologies, Regeneron, Sanofi and Teva, and consulting/speaker and honoraria/consulting fees from AstraZeneca, Regenerome Sanofi, and Teva. Hourihane reports being a speaker/advisory committee/clinical investigator and receiving honorarium from Aimmune Therapeutics, Inc., being a clinical investigator and receiving honorarium from DBV Technologies, being an independent contractor and receiving research funding from Johnson & Johnson and being a speaker and receiving honorarium from nutricia. Kim reports consulting honorarium from Aimmune Therapeutics, Inc., Allakos and AllerGenis, and being on the consulting/advisory committee and receiving honorarium from DBV Technologies.