Poor quality of life predicts use of peanut oral immunotherapy, but uptake remains low
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Poor quality of life was the primary reason why 9.3% of families pursued peanut oral immunotherapy, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
Even when patients with peanut allergy practice strict avoidance, incidence of accidental exposure to peanut is approximately 10% annually, and 30% of exposures require epinephrine and medical attention, according to Sara Patrawala, MD, allergy and immunology fellow at University of Rochester School of Medicine, and colleagues.
Because the use of FDA-approved peanut oral immunotherapy (POIT) may increase the threshold dose of peanut required to elicit a clinical reaction and improve quality of life (QoL), Patrawala and colleagues sought to determine the real-world adoption rates of POIT, and to understand the rationale for pursuing or declining POIT.
The prospective, observational study involved 237 participants (median age, 8 years; age range, 4-17 years; 65.4% boys) with peanut allergy treated at a hospital-based allergy/immunology practice between May 2020 and April 2021, Of the 237 participants, 150 (63.2%) reported additional food allergies.
The children, adolescents and parents involved in the study completed questionnaires about food allergy QoL before their allergists discussed POIT them. Higher scores indicated lower QoL.
Overall, 76.6% of the children completed the FAQL-CF with a median score of 95 (interquartile range [IQR], 34.5-138.7), and 80% of the adolescents completed the FAQL-TF with a median score of 71.5 (IQR, 32.7-107.5). All participants had a parent complete a questionnaire, with a median score of 33.3 (IQR, 19-59).
Twenty-two (9.3%) of the 237 participants chose FDA-approved POIT, most commonly for “protection against accidental ingestion.”
Children aged 8 to 12 years (OR = 1.01; 95% CI, 1-1.02; P < .001) and their caregivers (OR = 1.02; 95% CI, 1.01-1.04; P = .01) with low QoL were more likely to pursue POIT.
Also, children aged 8 to 12 years overall reported lower QoL than adolescents, and these families were more likely to pursue POIT. Poorer parental QoL was an independent factor for predicting pursuit of POIT, indicating the significant role of parental anxiety and QoL in POIT uptake, the researchers wrote.
Meanwhile, 215 (90.7%) declined therapy, primarily due to “concern over adverse effects” (35.4%) and “concern over the degree of commitment” (28.5%). The researchers indicated they were not surprised by these findings because patients receiving POIT experience more gastrointestinal side effects than those practicing strict avoidance.
A prior history of accidental peanut exposure, history of epinephrine use and comorbid food allergies did not influence the decision to pursue or decline POIT, the researchers found.
The influence of QoL on the decision to pursue POIT underscores the importance of shared decision-making between the allergist and families with peanut allergy, the researchers wrote.
Calling their study the first to evaluate real-world uptake of FDA-approved POIT, the researchers also said that future studies should further explore the adoption of POIT over time and in diverse clinical settings and patient populations.
Perspective
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The results of this study are surprising. Perhaps the study's main limitation — its use of a single practice with an affluent study cohort — played into the results. Another factor may be that 63.2% of the patients reported additional food allergies. Perhaps they didn't want to make the commitment given they would still have to avoid all the other foods, because treatment for those allergies was not offered. Additionally, there may have been issues with how the product and protocol were implemented into the clinic’s practice.
These results do not line up with my experience. Our clinic has successfully treated more than 1,000 patients with peanut allergies. A vast majority of patients who are offered POIT do it, and it is surprising when someone does not want to pursue POIT.
Perhaps the flexibility and individualization we have in our program and protocols allow for more people to have hope in the process and determine the commitment is worthwhile. We may have a selection bias in my clinic, because we are well-known for POIT, and people who are interested and motivated often seek us out.
Although there are potential side effects and POIT is a commitment, the alternative option of doing nothing is most often less appealing to most of our patients and parents. I would like to see additional studies with several clinics in a variety of demographics and see if there are differing results. It would be interesting to see the difference when treatment for the other food allergies is offered. There may be a difference in clinics that treat several food allergies and are not limited by one product.
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Peanut (Arachis hypogaea) allergen powder-dnfp (Palforzia, Aimmune Therapeutics) can offer some hope for individuals and families with life-threatening peanut allergies, as it could help protect against accidental ingestion and cross-contamination of peanuts.
However, the results of this study are not surprising considering that there are challenges and limitations to Palforzia regarding costs, dosing regimens, the extended course of treatment and the potential for side effects. In fact, these results line up with what I have seen in my own experience.
It’s important for doctors to understand the patient and family factors that can influence their consideration of Palforzia, or any treatment. Doctors and patients and their families then can work together to make the best health care decision based on balancing risks, challenges, outcomes, and the patient’s and family’s preferences in addition to QoL.
Next in this research, it would be helpful to see data from more diverse clinical settings and patient populations, as well as data on the length of treatment needed to achieve sustained tolerance.
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