Editors' ChoiceFood Allergy

SLITting Down the Peanut Allergy

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Science Translational Medicine  09 Jan 2013:
Vol. 5, Issue 167, pp. 167ec9
DOI: 10.1126/scitranslmed.3005598

A peanut butter and jelly sandwich is a popular snack for many children and even some adults, but the shadow of death lurks between the bread slices for peanut allergy sufferers. About 8% of U.S. children have food allergies, with peanut being the most common allergen that triggers fatal food-induced anaphylaxis. Peanut allergy is less commonly outgrown than are allergies to other foods and requires lifelong changes in dietary habits. To date, no safe therapeutic options exist for patients with peanut allergy. Now, Fleischer et al. examine the clinical effects and safety profile of peanut sublingual immunotherapy (SLIT) in a multicenter, randomized, placebo-controlled trial.

The authors recruited 40 participants aged 12 to 37 years from 5 U.S. cities. The study subjects underwent a baseline oral food challenge with up to 2 g of peanut powder and were then randomized to receive either peanut or placebo SLIT. The peanut SLIT dose was gradually escalated to a maintenance dose. At week 44, the placebo group crossed over to receive peanut SLIT. The primary end point was the percentage of desensitized participants measured with a 5-g peanut powder oral challenge after 44 weeks of therapy. Subjects successfully consuming 5 g or at least 10-fold more peanut powder than at baseline were considered responders. After 44 weeks of SLIT, a significantly higher response rate was noted in the active treatment group: 14 (70%) of 20 subjects receiving peanut SLIT were responders versus only 3 (15%) of 20 subjects receiving placebo. Desensitization was also observed in placebo subjects who were crossed over and received higher-dose peanut SLIT.

The study demonstrated that treatment of allergy patients with peanut SLIT induces a modest level of desensitization as compared with that of placebo. Longer duration of SLIT therapy in a subset of subjects showed a significant increase in the successfully consumed dose of allergen, suggesting that long-term therapy with SLIT might confer additional benefits in reducing reactivity to peanut.

This study was limited by a high dropout rate and by enrollment of patients with peanut allergy without a history of life-threatening reactions, which may have introduced a bias. About 40% of subjects receiving active SLIT reported allergic symptoms during the therapy, which could have affected the blinding of the study. Although further studies are needed to determine whether SLIT therapy is a safe and clinically useful treatment option for all peanut allergy sufferers, these findings are an important step toward deciphering peanut SLIT effects and safety in the treatment of peanut allergy.

D. M. Fleischer et al., Sublingual immunotherapy for peanut allergy: A randomized, double-blind, placebo-controlled multicenter trial. J. Allergy Clin. Immunol. 131, 119–127.e7 (2013). [PubMed]

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