Predefined Clinical and Laboratory Criteria Predict Successful Transition from Peanut Oral Immunotherapy Daily Maintenance Dosing to Ad Lib Consumption

Abstract

Peanut oral immunotherapy has been shown to effectively decrease sensitization in peanut-allergic individuals; however, clinical endpoints for completion of therapy remain unclear. We followed long-term outcomes in a real-world peanut OIT cohort that transitioned to ad lib peanut consumption once meeting predefined clinical and laboratory criteria. Data were collected for 199 patients initiating peanut oral immunotherapy (OIT) at a pediatric Allergy clinic between 2011-2020. Patients proceeded through clinic updosing to daily maintenance dose of 2 teaspoons peanut butter, or lower dose for toddlers or those with severe peanut aversion. Patients were permitted to transition to ad lib peanut consumption once meeting the following criteria: (1) tolerance of a full-serving of peanut (7000mg peanut protein) in oral food challenge, (2) Skin prick wheal <8mm, and (3) serum peanut-specific IgE level <1 kUA/L. Patients were advised to continue peanut consumption at least twice weekly during ad lib regimen. Clinical outcomes were monitored by clinic visits or telephone contact. Fifty-one of 199 patients transitioned to ad lib consumption after a median of 285 days since reaching daily maintenance (91-1183 days). Median time on ad lib status was 581 days (20-2,275 days). Two grade I reactions--oral itching and perioral rash--occurred after lapse in peanut intake for 2 weeks and 2 months, respectively. Eight patients (16%) continued to self-report peanut allergy, and 24 (48%) continued to carry epinephrine injectors. Peanut OIT patients identified prospectively by clinical and laboratory criteria can successfully transition from daily maintenance dosing to intermittent ad lib peanut consumption.