Multi-food Oral Immunotherapy as Safe and Effective as Single Food Therapy

Abstract

With peanut allergy therapies under development, peanutallergic children are completing clinical trials wishing to maintain desensitization. We describe our experience transitioning children to real food equivalents of peanut following trial completion. METHODS: Children who completed peanut clinical trials with interest in continuing (post-oral immunotherapy [OIT]) or starting (post-epicutaneous immunotherapy [EPIT]) daily peanut ingestion were offered an oral food challenge (OFC) for the starting dose, which was determined based on study dose/eliciting dose during exit OFC. Dose-escalation to 2000 mg peanut protein was offered. The charts of post-study participants transitioned to daily peanut ingestion from May 2016-May 2019 were reviewed. Families without recent follow-up were contacted by telephone. This study was IRB approved. RESULTS: Twenty children (80% male; median age 7.6 years, range 4-15 years; n55 post-EPIT, n515 post-OIT) were transitioned to daily peanut ingestion. The median starting dose was 300 mg (post-EPIT: 100 mg [range 30-300 mg]; post-OIT: 400 mg [range 30-2000 mg]). Four participants started at 2000 mg; 11/16 dose-escalated. Thirteen participants reached a daily dose >1000 mg. Median follow-up was 1.7 years. Seventeen participants (85%) continued dosing for at least one year or were confirmed to currently actively dose if transitioned in the past year. Two participants discontinued due to side effects (gastrointestinal, hives, wheezing); one was lost to follow-up. CONCLUSIONS: Most post-study children transitioned to daily peanut reached a maintenance dose of >1000 mg and continued dosing long-term with real food equivalents. This suggests that families are motivated to followthrough with daily peanut to maintain desensitization after study completion.

A practical focus on multi-food oral immunotherapy

“…The concept is sound, and several studies have shown multifood OIT to be as safe and effective as single-food therapy. 3 , 4 , 8 These studies observed similar reaction rates, time to reach the maintenance dose, and likelihood of reaching maintenance ( Table 1 ). Most commonly, two to three foods are used ( Table 2 ), although as many as five foods have been successfully administered simultaneously.…”

“…Oral immunotherapy (OIT) was introduced as single-allergen therapy, starting with peanut, but, over time, has evolved to the common practice of administering multiple allergens simultaneously. 1 – 4 The use of more than one food in an OIT course is referred to as multifood OIT. Combining foods in this fashion is an option for those with properly diagnosed food allergy to more than one, non–cross-reactive food.…”

Oral immunotherapy for food allergy: Translation from studies to clinical practice?

“…In a retrospective study of patients performing peanut OIT (n = 162) or multi-allergen OIT (2–4 allergens, n = 77), the time to reach the maintenance phase was comparable between patients receiving OIT for the allergen mix and those receiving OIT for peanut alone (231 versus 245 days). 47 Furthermore, the efficacy appeared to be comparable, as 80% of patients receiving multi-allergen OIT and 85% receiving peanut OIT reached the maintenance phase. The tolerance of multi-allergen OIT also appeared to be good in terms of the number of cases of anaphylaxis under OIT: after 1 year, adrenaline was used by 13% of patients in the peanut OIT group versus 8% of patients in the multi-allergen OIT group.…”

“…Few studies have evaluated the efficacy and tolerance of OIT for mixtures of food allergens. 46 , 47 The interest would be to be able to carry out OIT on multiple food allergic patients, in particular, those with an allergy to peanut and/or tree nuts, considering the interest of starting early in life and, in particular, the constraints associated with the implementation of OIT in a hospital environment. In a retrospective study of patients performing peanut OIT (n = 162) or multi-allergen OIT (2–4 allergens, n = 77), the time to reach the maintenance phase was comparable between patients receiving OIT for the allergen mix and those receiving OIT for peanut alone (231 versus 245 days).…”

Oral Immunotherapy in Children: Clinical Considerations and Practical Management

“… 20 A recent retrospective review comparing peanut and mOIT also demonstrated the safety of combining multiple foods into one OIT mix. 21 All patients underwent a dose escalation phase, after which 85% of POIT patients and 80% of mOIT patients reached the maintenance dose. The median time to reach maintenance dose, changes in sIgE levels, and percentage of patients requiring epinephrine during treatment were comparable between both groups.…”