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Background: Peanuts are a member of the legume family (botanical family Leguminosae) and peanut allergies are the most common cause of food anaphylaxis in many countries. The prevalence of peanut allergy is increasing.
Methods: Experts from Germany and Austria performed a standardized literature search and published their consensus recommendations in a White Paper on Peanut Allergy, which this care pathway is based upon, thus, providing a comprehensive diagnosis and treatment algorithm.
Results: The most important diagnostic key elements include a detailed clinical medical history, evidence of peanut-specific sensitization by means of skin prick testing and/or in vitro determination of the peanut (extract)-specific IgE and/or the molecular component diagnostics (most important Ara h 2-specific IgE, sometimes also Ara h1-, 3-, 6-, 8- and 9-specific IgE) as well as the gold standard, the double-blind, placebo-controlled food challenge. The diagnostic algorithms were created for the following constellations: Suspected primary peanut allergy with a clear history of systemic immediate-type reaction, suspected primary peanut allergy with questionable symptoms, suspected secondary (possibly pollen-associated) peanut allergy with a history of solely oropharyngeal symptoms and incidental finding of sensitization and no peanut ingestion so far.
Conclusions: After established diagnosis the standard of care is counseling to avoid peanut contact and prescription of emergency medications (oral antihistamines, oral steroids, inhaled β2-agonists, injectable intramuscular epinephrine) as needed. Instruction on the use of these emergency medications should be provided. A preparation for oral immunotherapy (OIT) for 4 to 17 years old peanut allergic children/ adolescents has been recently approved by the regulatory authorities. OIT for peanut allergy shows high efficacy and an acceptable safety profile, improves quality of life, and health economic aspects. Thus it offers a therapeutic option for peanut allergic children and adolescents.
White paper peanut allergy
(2022)
The current management of a primary IgE-mediated peanut allergy consists of the two basic pillars “exposure prophylaxis” with avoidance of the allergen and “emergency therapy” with short-term treatment of an acute allergic reaction after accidental ingestion. Accidental reactions are common despite attempted avoidance. The severity of an allergic or even anaphylactic reaction after accidental ingestion is difficult to assess prior to reaction. In addition, reaction thresholds may vary depending on the accompanying augmentation factor. Therefore, every peanut allergic patient should receive individual dietary counseling as well as instructions for the use of the emergency kit and a structured patient education program (anaphylaxis group training), if necessary. For the first time, since fall 2021 a causal treatment option with a drug for oral immunotherapy will now be available for 4‑ to 17-year-old peanut-allergic children and adolescents. The oral immunotherapy with peanut protein as defatted powder of Arachis hypogaea L., semen (peanuts) leads to desensitization with a good efficacy record and an acceptable safety profile. Other treatment options with different therapeutic approaches are also under development and will probably expand the range for treatment in the coming years.
Strong dose response after immunotherapy with PQ grass using conjunctival provocation testing
(2019)
Background: Pollinex Quattro Grass (PQ Grass) is an effective, well-tolerated, short pre-seasonal subcutaneous immunotherapy to treat seasonal allergic rhinoconjunctivitis (SAR) due to grass pollen. In this Phase II study, 4 cumulative doses of PQ Grass and placebo were evaluated to determine its optimal cumulative dose.
Methods: Patients with grass pollen-induced SAR were randomised to either a cumulative dose of PQ Grass (5100, 14400, 27600 and 35600 SU) or placebo, administered as 6 weekly subcutaneous injections over 31–41 days (EudraCT number 2017-000333-31). Standardized conjunctival provocation tests (CPT) using grass pollen allergen extract were performed at screening, baseline and post-treatment to determine the total symptom score (TSS) assessed approximately 4 weeks after dosing. Three models were pre-defined (Emax, logistic, and linear in log-dose model) to evaluate a dose response relationship.
Results: In total, 95.5% of the 447 randomized patients received all 6 injections. A highly statistically significant (p < 0.0001), monotonic dose response was observed for all three pre-specified models. All treatment groups showed a statistically significant decrease from baseline in TSS compared to placebo, with the largest decrease observed after 27600 SU (p < 0.0001). The full course of 6 injections was completed by 95.5% of patients. Treatment-emergent adverse events were similar across PQ Grass groups, and mostly mild and transient in nature.
Conclusions: PQ Grass demonstrated a strong curvilinear dose response in TSS following CPT without compromising its safety profile.
The current management of a primary IgE-mediated peanut allergy consists of the two basic pillars “exposure prophylaxis” with avoidance of the allergen and “emergency therapy” with short-term treatment of an acute allergic reaction after accidental ingestion. Accidental reactions are common despite attempted avoidance. The severity of an allergic or even anaphylactic reaction after accidental ingestion is difficult to assess prior to reaction. In addition, reaction thresholds may vary depending on the accompanying augmentation factor. Therefore, every peanut allergic patient should receive individual dietary counseling as well as instructions for the use of the emergency kit and a structured patient education program (anaphylaxis group training), if necessary. For the first time, since fall 2021 a causal treatment option with a drug for oral immunotherapy will now be available for 4‑ to 17-year-old peanut-allergic children and adolescents. The oral immunotherapy with peanut protein as defatted powder of Arachis hypogaea L., semen (peanuts) leads to desensitization with a good efficacy record and an acceptable safety profile. Other treatment options with different therapeutic approaches are also under development and will probably expand the range for treatment in the coming years.