Recently, thousands of researchers, allergists, physicians, nurses, registered dietitians and other healthcare professionals from around the world met to share the latest research and updates. Food allergies were a significant part of the conversations and presentations. I’ve broken down some of the highlights of the four-day conference below.
Preventing Peanut Allergy: Implementation of the NIAID Guidelines
Several sessions throughout the conference focused on the 2017 NIAID Addendum Guidelines for the Prevention of Peanut Allergies in the United States. With the release of the LEAP study results in 2015, followed by the 2016 Consensus Statement and then the NIAID Guidelines in early 2017, many practitioners are aware of the latest recommendations to introduce peanut foods early. However, knowing the guidelines and implementing them are two different things and there are many outstanding questions, unintended consequences and some barriers that still need to be overcome. The challenges were clearly laid out in a variety of sessions, including via oral abstracts sharing real-life challenges in systems throughout the country and in a workshop session where practitioners shared their questions and concerns. Some of the key takeaways include:
- Many healthcare professionals still don’t know about the new guidelines. In spite of all of the hype and effort to spread the word, work is still needed to help ensure that all primary care physicians and pediatricians are up to date. (Chang)
- There are multiple ways that training could be delivered to raise awareness and compliance with the new guidelines. Ideas for increasing awareness and adherence included web-based training; utilizing in-person Grand Rounds to train non-allergists; inserting screening questionnaires into electronic medical records to prompt screening during early-infant well visits; and additional electronic training.
- Screening is not happening consistently and accurately. One analysis showed that zero of the potentially high-risk infants in one clinic were properly screened and referred for testing and early introduction of peanut foods. (Russo)
- Too much lag-time exists between the time high-risk infants are identified and supervised feedings occur – potentially missing the window for avoiding allergy. Case examples shared showed that the size of a skin prick test (SPT) for infants from the time they were identified as “at risk” increased by at least two. In some cases, that removed their chance for having in-office introduction of peanut foods and into a total avoidance recommendation. In short, high-risk patients who miss the critical window of 4-6 months for introduction may be significantly more likely to become allergic while they wait to see a specialist for an in-office peanut introduction.
- Allergists must work very closely with pediatricians in the community in order to successfully implement the guidelines. As pediatricians, and perhaps even obstetric and gynecologists, are the ones giving early advice on infant feeding, well before complementary feeding starts, pediatricians need to be screening and referring very early (perhaps in the 2-3 month window). Local allergists need to be ready to fast-track these high-risk infants into their practice in order to be part of the solution. (Pratt)
- One thing that can help encourage allergists regarding in-office introductions is that positive reactions were almost all mild in infants. In one review of 123 infants who met the screening criteria, 66.7% were referred to at-home introduction and 20% were recommended to have in-office introduction. Only 12 infants were returned for testing with 11 having some sort of reaction; and anaphylaxis occurred in only one high-risk infant. (Stukus)
Managing Food Allergies
Diagnosis of food allergies continues to rely on history, skin and blood tests, and – the gold standard – oral food challenges. Skin and blood tests have high percentages of false positive results, which may result in many inaccurate diagnoses for food allergies. However, research on using basophil activation testing (BAT) continues to evolve. At this time, it is available only in a research capacity. Component testing (looking at specific proteins within a whole food) is a useful adjunct but does not replace oral food challenges. There are no additional specific tests imminently available for diagnosing food allergies.
Food allergy labeling is an area of ongoing concern for food allergy families and experts alike. In particular, precautionary labeling continues to be a big issue. Because precautionary labels (e.g. may contain) are voluntary and unregulated, potentially dozens of different statements can be found on food packages. This leads to confusion amongst allergic individuals and results in them either (1) avoiding far more foods than necessary or (2) ignoring warnings altogether, which may increase their risk. Allergic individuals should not eat foods that contain precautionary labels about their food allergen. In addition, in the U.S. only eight potential allergens are required to be called out on labels. Many more foods can cause reactions, leaving a significant gap for those with allergens besides the “big 8”.
In schools, food allergy management is an important topic. Research shows that there are a variety of potentially helpful strategies for reducing the risks of accidental ingestion and some strategies that do not reduce risk. These are the highlights presented by Michael Young, MD at the conference:
- Researchers have found that epinephrine use is not lower in schools that claim to be peanut-free.
- Ingestion may cause anaphylaxis, but casual contact, such as being near someone eating peanut foods or attending a school where peanut foods are allowed, does not.
- Food bans don’t reduce the risk of reactions but having allergen-free tables may.
- New guidelines from AAAAI regarding the role of the allergist in managing food allergies in schools are forthcoming.
Immunotherapy to Treat Peanut Allergy
DBV’s Epicutaneous Immunotherapy (EPIT) “Peanut Patch” has been proven safe and somewhat effective in subjects 4-11 years. There was a significant improvement in tolerance as compared to placebo. In the study reported, 356 subjects ages 4-11 years participated in the peanut patch therapy with the goal of allowing them to tolerate oral peanut protein. Of the participants, 35.3% tolerated 300mg peanut protein, as compared to only 13.6% of the placebo after 12 months of therapy. Although this was a positive outcome, the study did not meet its overall goal. (Fleischer et al.)
In the area of Oral Immunotherapy (OIT), there were several interesting presentations showing positive results. In one study, researchers from Israel reported positive outcomes for subjects participating in OIT, even at low doses. This is significant, because some subjects stop OIT treatments due to negative side effects; however, if those allergic individuals continue treatment, they may still achieve benefits. In fact, in the study presented, all but one individual (n=11 patients between 6-9 years old) who received lower doses of OIT achieved tolerance according to their oral food challenge, even though their maintenance dose was lower than the protocol goal. The learning is that for patients unable to progress in the dosing schedule for OIT, continuing to participate at a lower, better tolerated dose may still result in successful desensitization. (Nachshon, et al.)
The results of the Aimmune PALISADE OIT for peanut trial has shown good efficacy and safety. Of the 372 participants in the trial (allergic individuals ages 4-17 years), 79.6% completed the trial. Of the intent-to-treat, 76.6% could tolerate 300mg peanut protein at the end of the trial (67.2% could tolerate 600mg, 50.3% could tolerate 1000mg). When considering those who actually completed the trial, 96.3% were able to tolerate 300mg peanut protein (84.5% could tolerate 600mg and 63.2% were able to tolerate 1000mg). The study met both primary and secondary goals for outcomes of this phase 3 clinical trial. Aimmune reports that they expect to submit their request to FDA for license by the end of 2018. (L6, Jones, et al.)
Survey of food allergy anaphylaxis management in North Carolina Schools:
Data was collected at a large school district with a population of approximately 160,000 students. The district food allergy management policies include: offering the use of individual placemats for food allergy students; implementing a no-food-sharing policy; wiping cafeteria tables with water between groups; and performing proper hand hygiene before and after food handling for all students. (Neighbors)
- During the 2016-17 year, 1,878 students (1.17%) had a clearly-defined food allergy management plan.
- Eight reactions (0.4%) required use of epinephrine autoinjectors.
- One of these eight was due to a known food allergy exposure. Five of eight episodes were administered for unknown exposures, and three were due to allergies other than food.
*Featured Image Source: http://annualmeeting.aaaai.org/