Clinicians are increasingly recognizing the impact of peanut allergy on quality of life for patients and their parents. “Over the past few years, huge strides have been with advances in peanut allergy prevention, treatment, and advocacy,” explains Matthew Greenhawt, MD, MBA, MSc. “However, despite these advances, some issues still need to be addressed regarding unanswered questions, issues of dissemination/implementation, and future directions.”

Dr. Greenhawt was part of an expert panel from the Allergy & Asthma Network that set out to highlight knowledge gaps and needs surrounding peanut allergy. Literature searches of PubMed were conducted to evaluate published data on prevention, treatment, and risk stratification strategies to address peanut allergy reactions after unintentional or incidental exposures.

Results from the expert panel review—published in Annals of Allergy, Asthma, & Immunology—identified key unmet needs in the prevention and management of peanut allergy. These include enhancing and optimizing implementation of early peanut introduction as a prevention strategy; developing knowledge translation strategies on efficacy and safety data for current and emerging immunotherapies to support their use in clinical practice; and promoting an understanding of true exposure risk in those who are allergic. “Our paper sought to provide some context regarding these issues and how they can be solved,” Dr. Greenhawt says.

Screening

The National Institute of Allergy and Infectious Diseases guidelines provide a framework for early peanut introduction. However, questions remain about implementing early introduction and the definition of a high-risk infant (Table). According to Dr. Greenhawt, the early introduction policy in the United States is different from other western nations in that it strongly recommends screening high-risk infants for peanut allergy through skin testing prior to introduction. “We understand many of the issues with screening before early introduction and how parents may feel somewhat conflicted about this issue,” he says. “However, when compared with a universal introduction strategy, research suggests screening is less cost effective and prevents fewer peanut allergy cases over a 20-year horizon. Screening is also proving difficult to implement.”

Emerging Treatments

Researchers continue to explore the efficacy and safety of oral immunotherapy and epicutaneous immunotherapy to help manage peanut allergy. While one product was recently FDA approved, other products are being investigated in phase 3 clinical trials. “Fortunately, our treatment options are expanding,” says Dr. Greenhawt. “When selecting treatment, it is important to consider risks, benefits, and tradeoffs as well as the nuanced arguments regarding these approaches.”

Choosing a therapy or deciding to enter into treatment is a shared decision and must be considered in the context of expected goals, desired outcomes, and willingness to accept potential side effects and limitations with therapy effectiveness, according to Dr. Greenhawt. “There is no right choice per se,” he says. “Ultimately, treatment decisions are a highly individualized process for most families.”

Unintentional & Casual Exposures

A key focus of patient management should be to enhance adherence with anaphylaxis self-management planning by empowering patients and parents to handle unintentional and causal exposures. Anxiety about peanut allergy and the risk of unpredictable consequences remains difficult to manage. “There are many myths and misperceptions regarding risks of environmental peanut exposure, some of which have influenced policy,” says Dr. Greenhawt. “Key misperceptions include the likelihood of fatality and policies to help decrease risks for fatality.”

Clinicians are recommended to foster partnerships with patients to keep them informed about the actual risks associated with their peanut allergy. “Fear-based messaging is problematic and may have negative ramifications on anxiety and quality of life,” Dr. Greenhawt says. “We need strategies to emphasize facts over fear, so patients understand and contextualize their risk. We also need to better understand how best to communicate these issues.”

In the future, Dr. Greenhawt recommends conducting more pragmatic trials to optimize current approaches. “We need to strive to develop innovative treatment strategies and continue to investigate the current pipeline,” he says. “Finding interventions to decrease anxiety about peanut allergy and strategies to improve quality of life are paramount to debunking myths and misconceptions.”

References

Chan ES, Dinakar C, Gonzales-Reyes E, et al. Unmet needs of children with peanut allergy: aligning the risks and the evidence. Ann Allergy Asthma Immunol. 2020;124(5):479-486. Available at: https://www.sciencedirect.com/science/article/pii/S1081120620300375.

Waggoner MR. Parsing the peanut panic: the social life of a contested food allergy epidemic. Soc Sci Med. 2013;90:49e55.

Greenhawt M, Oppenheimer JJ. Life in the FAST lane. Ann Allergy Asthma Immunol. 2018;121:264-265.

Venter C, Sicherer SH, Greenhawt M. Management of peanut allergy. J Allergy Clin Immunol Pract. 2019;:345-355.