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9th August 2021
An estimated approximately 2% of the population of Western nations has a peanut allergy. However, the prevalence in the paediatric population is likely to be higher with one study of 3218 finding that 24.8% had a childhood peanut allergy. The presence of a peanut allergy has the potential to cause life-threatening reactions and elicit anaphylaxis in both children and adults. While the standard approach for those with a peanut allergy is allergen avoidance and the use of adrenaline auto-injection as a treatment for any allergic reactions following accidental ingestion, a peanut allergen powder, Palforzia, has been approved for use in the EU since 2020. Palforzia contains peanut protein as a defatted powder and has a marketing authorisation for the treatment of patients aged 4 to 17 years with a confirmed diagnosis of childhood peanut allergy. Treatment with Palforzia is a form of oral immunotherapy that involves ingesting, small and controlled amounts of peanut protein with the aim of desensitising children and ultimately reducing the risk of life-threatening allergic reactions. However, continued treatment is required because once therapy is discontinued, reactivity to peanuts reoccurs.
The efficacy of Palforzia in childhood peanut allergy has been demonstrated in two Phase III randomised, controlled trials. In the first trial (PALISADE), 67% of participants who received Palforzia were able to ingest a dose of 600mg of peanut protein without any problems, compared to 4% of those assigned to placebo. In the second and more recent trial (ARTEMIS), 58% of those given Palforzia could tolerate 1000mg of peanut protein without problems compared with only 2% in the placebo group.
The same group have now reported follow-up data for patients who completed the PALISADE study in an open-label extension study. Individuals with childhood peanut allergy received 300mg/day for either 1.5 years (group A) or a total of 2 years (Group B). The primary outcome of the trial was a double-blind, placebo-controlled food challenge (DBPCFC), which involves supervised and gradual ingestion of the suspected food allergen (peanuts) disguised or hidden in another food.
The extension study included 142 participants aged 4–17 years (110 in Group A). The median age of group A was 10 years (52.7% male) whereas the median age of group B was 8 years (56.2% male). The percentage of participants able to tolerate the highest DBPCFC (2000mg peanut protein) and without any dose-limiting symptoms was 80.8% in group B compared with 48.1% in group A. In addition, the proportion of individuals requiring adrenaline as a rescue medication was 24% (group A) and only 3.8% (group B).
The researchers described how the data indicated that the extent of desensitisation to childhood peanut allergy was clearly time-dependent in how efficacy appeared to increase over time. They concluded that longer-term data will be captured from this ongoing study to determine whether continued therapy improves DBPCFC response.
Fernandez-Rivas M et al. Open-label follow-on study evaluating the efficacy, safety, and quality of life with extended daily oral immunotherapy in children with peanut allergy. Allergy 2021
27th July 2021
Self-reported food allergy is relatively common, with one European analysis identifying a pooled lifetime prevalence of 17.3%. Furthermore, the presence of a food allergy negatively affects an individuals’ quality of life across all ages, with one study finding that the risk of accidental allergen ingestion and limitations in social life are associated with a worse health-related quality of life. The provision of allergy information has been incorporated into EU law since 2016 and requires that there is a clearer and harmonised presentation of allergens such as nuts, soy etc, on pre-packed foods and mandatory allergy information on non-prepacked foods in outlets such as bars and cafes. The introduction of precautionary allergen labelling (PAL), is the voluntary way used by food producers to warn consumers of the risks from the unintended presence of specific allergens in products, though PAL is not formally regulated in the EU. Despite the legal labelling requirements, allergic reactions remain common, with one study finding that 46% of adults reported an allergic reaction and 41% of these reactions occurred to pre-packed foods. However, it has also been found that consumers find a wide and inconsistent range of ways in which allergy information is presented on labels.
In an attempt to better understand how both allergy and non-allergy sufferers interpret and assess allergen information, a team from the Institute for Health Services Research, Utrecht, The Netherlands, evaluated consumer understanding of allergy information on foods in a controlled, environment. The team looked at how consumers interpreted the information presented in three scenarios. In the first, consumers rated the risk of consumption by someone with an allergy from a mixed set of 18 products which contained the allergy information. Secondly, six of the 18 products were labelled “may contain peanut”, six had “peanut as an ingredient” and for the remaining six, there was no mention of peanut as an ingredient. Finally, individuals were asked to assess three different PAL labels, i.e., “may contain peanut” vs “may contain traces of peanut” vs “produced in a factory which also processes peanut”, using a 5-point scale.
For the ingredient experiment, 102 individuals with a mean age of 33.9 years (79% female) and 48 nonallergic consumers, similarly rated the risk of eating an allergen containing food. The PAL experiment involved 99 participants and found that those without an allergy judged the risk assessment to higher than those with an allergy (82% vs 58%, p < 0.01). The PAL for which participants expressed the highest preference was “may contain nuts” (65.7%), whereas the least preferred was “produced in a factory which also processes peanuts” (26.3%).
In their discussion, the authors noted how consumers appeared to attribute different risks, depending on the presentation of allergy information on a food label. However, overall, only around 50% of consumers judged that the allergy information was clear. They concluded by calling for allergy information guidelines to ensure that the information is much clearer and understood by consumers.
Holleman BC et al. Poor understanding of allergen labelling by allergic and non- allergic consumers. Clin Exp Allergy 2021
1st October 2020
In the present study, a team from the Paediatric Allergy Research group, Kings College, London, focused on the development of coeliac disease at 3 years of age, after the introduction of gluten, a protein present in wheat that triggers the disease, from 4 months of age. A total of 1004 infants from the general population of England and Wales, were enrolled in the study and were all breast-fed until 13 weeks of age, after which they were randomised to consume six allergenic foods; cow’s milk, hen’s egg, peanut, sesame, cod fish and wheat in addition to breast milk (intervention group) or to continue with exclusively with breast milk until 6 months of age (control group), as recommended by UK government guidelines. The weekly recommended dose of wheat for a child was set at 4g of wheat protein and this was provided as wheat-based cereal biscuits (Weetabix) or equivalent. The team calculated that this was equivalent to a gluten dose of 3.2g/week and though this was set as the minimum intake, no maximum limits were set. The families were asked to complete weekly questionnaires through to 1 year and then every 3 months until 3 years of age.
For the 1004 (488 given the allergenic foods) infants included in the final analysis, 514 were male (51.2%) and the mean gluten intake between ages 4 and 6 months was 0.49g/week for the control group compared to 2.66g/week for the intervention group. At 8 months of age, gluten consumption had increased to 8.21g/week in the intervention group. Interesting by 3 years of age, 7 children in the control group but none of those in the gluten group, at developed coeliac disease.
Given the relatively small sample size, the authors called for more studies to confirm whether early introduction of gluten is an effective strategy to prevent the development of coeliac disease.
Logan K et al. Early gluten introduction and celiac disease in the EAT study. A prespecified analysis of the EAT randomised clinical trial. JAMA Pediatr doi:10.1001/jamapediatrics.2020.2893