Engagement key to peanut oral immunotherapy compliance among adolescents

Key takeaways:

• Successful peanut oral immunotherapy requires strict compliance.
• Adolescents’ need for independence may challenge positive outcomes.
• Engaging with patients and parents can improve results.

LOUISVILLE, Ky. — Communication can improve compliance and outcomes among teenagers on peanut oral immunotherapy, according to a presentation at the American College of Allergy, Asthma & Immunology Annual Scientific Meeting.

“We need to engage adolescents right from the beginning of the process,” Monica G. Ghoshhajra, MD, allergist and immunologist at Lahey Hospital and Medical Center in Burlington, Massachusetts, said during her presentation.

Peanut OIT involves gradually increasing doses of purified peanut protein consumed in capsule form over three separate phases. The first phase comprises five sequential and escalating doses given over a single day.

“If this is tolerated, the following day, the patient returns to start the up-dosing phase, which involves increasing doses given every 2 weeks in the office with at-home doses given in between,” Ghoshhajra said.

Phase three is the maintenance phase, where the patient achieves and continues a 300 mg dose at home every day indefinitely.

“Doses are ideally consumed in the evening after a meal and with parental supervision one hour after,” Ghoshhajra said. “Patients are advised not to perform strenuous activity or take hot showers from 1 hour before or 3 hours after the dose.”

Ghoshhajra then described a boy aged 17 years with a history of peanut and tree nut anaphylaxis and asthma, as well as a serum peanut IgE of 23.9 kU/L and a 31 mm wheal following a skin prick test. After extensively discussing the protocol with the clinicians, the family enrolled in the immunotherapy program.

“We also discussed the risk evaluation and mitigation strategy program, which is a contract that all involved parties must complete to acknowledge the inherent risks,” Ghoshhajra said.

The clinic provided the family with a binder including information about correct dosing procedures, a summary of in-office doses, a log for tracking daily doses at home and contact information for the clinic before the therapy began.

The patient began taking peanut (Arachis hypogaea) allergen powder-dnfp (Palforzia, Aimmune Therapeutics), which Ghoshhajra called the first and only FDA-approved therapy designed to protect patients with peanut allergy from anaphylaxis due to accidental exposures, in November 2021.

The patient developed very mild abdominal pain as doses began to escalate in a self-limited manner, Ghoshhajra said, and he returned for up-dosing as scheduled. However, issues emerged as treatment progressed.

“Early on, he would forget to eat breakfast, and we would provide him food from our clinic,” Ghoshhajra said.

Also, the patient ate a cookie with tree nuts on Christmas Eve and developed anaphylaxis, which was followed by a visit to the ED and three doses of epinephrine.

“The ED physician did not consult allergy and recommended that he withhold his Palforzia dose for several days,” Ghoshhajra said. “His family only informed the office 2 days after the visit. He was able to immediately resume dosing without issues.”

During a February visit, the patient’s father said that the patient had been experiencing abdominal pain and diarrhea in the first week of a new up-dose during the previous month.

“The patient then admitted he occasionally took doses very late at night, often after his parents were already asleep, and on an empty stomach,” Ghoshhajra said. “A few times, he took the dose with dinner and then went to the gym within a few hours.”

The clinicians reviewed the proper dosing protocol with the patient and his parents, warning them that treatment would have to stop if he remained noncompliant. The clinicians also encouraged the patient’s parents to be more involved.

The patient then began taking doses as directed, including daily doses of famotidine to address his gastrointestinal symptoms, and achieved maintenance dosing in April 2022. In June 2022, the patient discontinued treatment.

Ghoshhajra noted that the clinicians had to consider certain factors in this case that younger patients do not present.

“Older teenagers have a strong need for autonomy. They are learning how to be self-sufficient and want independence from their parents,” she said.

Academics, extracurricular activities, family and social lives can present obstacles as well, Ghoshhajra said.

“We must find out how and if Palforzia can realistically fit into their lives,” she said, adding that many potential solutions are available.

In addition to communicating directly with adolescents from the beginning of treatment, Ghoshhajra suggested, mobile apps that track doses and remind patients to take them represent one possible solution. Parental engagement and psychosocial assessments also would help, she continued.

“We need to have the parents get actively involved and find out if social aspects could contribute to noncompliance,” Ghoshhajra said. “By anticipating problems and coming up with realistic solutions, we can help make this therapy a safe and successful treatment for any child.”