Delayed symptoms and orthostatic intolerance following peanut challenge

Turner, Paul J.; Ruíz-García, Mónica; Patel, Nandinee; Abrantes, Gonçalo; Burrell, Sarah; Vazquez‐Ortiz, Marta; Skypala, Isabel; Durham, Stephen R.; Boyle, Robert

doi:10.1111/cea.13865

Cited by 7 publications

(7 citation statements)

References 27 publications

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“…The recurrence of anaphylaxis symptoms following initial resolution may be a “biphasic” reaction but can also represent (and be difficult to distinguish from) protracted anaphylaxis with a transient response to adrenaline, or in the case of food-induced reactions, further allergen absorption from the gastrointestinal tract. 75 Historical guidelines have suggested a rate of up to 20% for biphasic reactions, however a recent meta-analysis reported a pooled rate of 4.6% (95% CI 4.0–5.3). 33 A rate of 4.7% has been reported in the European Anaphylaxis Registry.…”

Section: Introductionmentioning

confidence: 99%

Evidence update for the treatment of anaphylaxis

et al. 2021

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The Resuscitation Council UK has updated its Guideline for healthcare providers on the Emergency treatment of anaphylaxis. As part of this process, an evidence review was undertaken by the Guideline Working Group, using an internationally-accepted approach for adoption, adaptation, and de novo guideline development based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) evidence to decision (EtD) framework, referred to as GRADE-ADOLOPMENT. A number of significant changes have been made, which will be reflected in the updated Guideline.These include: emphasis on repeating intramuscular adrenaline doses after 5 min if symptoms of anaphylaxis do not resolve; corticosteroids (e.g. hydrocortisone) no longer being routinely recommended for the emergency treatment of anaphylaxis; interventions for reactions which are refractory to initial treatment with adrenaline; a recommendation against the use of antihistamines for the acute management of anaphylaxis; and guidance relating to the duration of observation following anaphylaxis, and timing of discharge.

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Section: Introductionmentioning

confidence: 99%

Evidence update for the treatment of anaphylaxis

et al. 2021

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“…Firstly, participants were eligible for OIT based on a positive history of peanut allergy and positive peanut skin prick test (8 mm) or peanut‐specific IgE (15 kU/L) at screening, rather than failing an OFC at study entry. This approach was selected based on pragmatic reasons including limitations in accessing hospital services to conduct OFC and safety concerns associated with conducting OFC in children with peanut allergies (where symptoms can be delayed following OFC) 18,19 . Furthermore, previous studies have reported high positive predictive value (94%) of using a combination of a positive peanut skin prick test (8 mm) or peanut‐specific IgE (15 kU/L) to determine likely peanut allergy 20–22 .…”

Section: Discussionmentioning

confidence: 99%

“…This approach was selected based on pragmatic reasons including limitations in accessing hospital services to conduct OFC and safety concerns associated with conducting OFC in children with peanut allergies (where symptoms can be delayed following OFC). 18,19 Furthermore, previous studies have reported high positive predictive value (94%) of using a combination of a positive peanut skin prick test (8 mm) or peanut-specific IgE (15 kU/L) to determine likely peanut allergy. [20][21][22] Secondly, we did not employ the use of a control or placebo group.…”

Section: Grade Grade Gradementioning

confidence: 99%

Oral immunotherapy using boiled peanuts for treating peanut allergy: An open‐label, single‐arm trial

Grzeskowiak

Tao

Aliakbari

et al. 2023

Clin Experimental Allergy

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Background Peanut allergy affects 1%–3% of children in Western countries. Boiling peanuts has been demonstrated to result in a hypoallergenic product that may provide a safer way of inducing desensitization in peanut‐allergic patients by first inducing tolerance to boiled peanut. We aimed to assess the efficacy and safety of oral immunotherapy (OIT) using sequential doses of boiled peanuts followed by roasted peanuts for treating peanut allergy in children. Methods In this open‐label, phase 2, single‐arm clinical trial, children aged 6–18 years with a positive history of peanut allergy and positive peanut skin prick test ≥ 8 mm and/or peanut‐specific IgE ≥ 15 kU/L at screening underwent OIT involving sequential up‐dosing with 12‐hour boiled peanut for 12 weeks, 2‐hour boiled peanut for 20 weeks and roasted peanut for 20 weeks, to a target maintenance dose of 12 roasted peanuts daily. Primary outcome: proportion of children passing open‐label oral food challenge involving cumulative administration of 12 roasted peanuts (12 g peanuts; approximately 3000 mg peanut protein) 6–8 weeks after reaching the target maintenance dose. Secondary outcomes included treatment‐related adverse events and use of medications for treating allergy symptoms. Results Between 1 July 2017 and 22 June 2018, 70 participants were enrolled and commenced OIT. Desensitization was successfully induced in 56 of 70 (80%) participants. Withdrawal due to treatment‐related adverse events was infrequent (n = 3). Treatment‐related adverse events were reported in 43 (61%) participants, corresponding to a rate of 6.58 per 1000 OIT doses. Medication use associated with treatment‐related adverse events was infrequent, with rescue epinephrine use reported by three (4%) participants (0.05 per 1000 doses). Conclusion Oral immunotherapy using boiled followed by roasted peanuts represents a pragmatic approach that appears effective in inducing desensitization and is associated with a favourable safety profile.

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“…However, we recently published data suggesting that vasovagal instability, resulting in orthostatic intolerance, can occur in up to 11% of participants reacting to peanut at a supervised food challenge. 26 This suggests a lack of awareness that such symptoms can occur during food-induced allergic reactions and might not suggest anaphylaxis (in terms of cardiovascular compromise due to distributive shock).…”

Section: Discussionmentioning

confidence: 99%

Improving Severity Scoring of Food-Induced Allergic Reactions: A Global “Best-Worst Scaling” Exercise

Stafford

Bartra

Aston

et al. 2021

The Journal of Allergy and Clinical Immunology: In Practice

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Background There is no current consensus on assigning severity to food-induced allergic reactions, for example, to assess the efficacy of allergen immunotherapy. Existing severity scores lack the capability to discriminate between non-anaphylaxis reactions of different severities. Attempts are ongoing to develop a more discriminatory score, which should ideally be data-driven and validated in multiple cohorts. Objective To undertake an exercise using best-worst scaling (BWS) to define a potential gold standard against which severity scoring of food-induced allergic reactions can be refined. Methods We undertook a global survey to better understand how health care professionals rate the severity of food-induced allergic reactions, using BWS methodology. Respondents were given a number of patient case vignettes describing real-world allergic reactions and asked to select the pair that, in their opinion, reflected the maximum difference in severity. Responses were then modeled and a preference score (representing severity) determined for each scenario. Scenarios were also scored using existing published scoring systems and the scores compared with the BWS score using Spearman r correlation and Cohen kappa. Given the differences in definitions of anaphylaxis globally, we also evaluated differences in BWS ranking depending on the geographical location of respondents. Results We received 334 complete responses, 183 (55%) from Europe and 65 (20%) from North America. Perception of severity of some reactions appeared to be affected by geographical location. The comparison of BWS ranking with current grading systems identified significant issues that varied from one grading system to another, such as prominence to some symptoms (eg, vomiting) that skew grading when using scoring systems not designed for food allergy. In general, current scoring systems poorly discriminate against more mild symptoms and often overestimate their severity. Conclusions These data provide a methodology free of user scale bias to help define a potential, consensus-driven gold standard that can be used to guide and validate the development of improved grading systems to score food-induced allergic symptoms and highlight areas for education where there is the potential to miscategorize severity.

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Delayed symptoms and orthostatic intolerance following peanut challenge

Abstract: This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Cited by 7 publications

References 27 publications

Evidence update for the treatment of anaphylaxis

Evidence update for the treatment of anaphylaxis

Oral immunotherapy using boiled peanuts for treating peanut allergy: An open‐label, single‐arm trial

Improving Severity Scoring of Food-Induced Allergic Reactions: A Global “Best-Worst Scaling” Exercise

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