Reduced peanut OIT dose offers safer, accessible treatment for children

Children with peanut allergies may not need large doses of peanut oral immunotherapy (OIT) to build protection to peanut, finds a new study led by The Hospital for Sick Children (SickKids) and Montreal Children's Hospital. Researchers found that a small dose can help children with their peanut allergy and reduce the risk of severe reactions from accidental exposures, with less side effects than the current standard treatment. 

In Canada, peanut allergies affect almost two per cent of children and adults and increasingly contribute to hospital admissions. Peanut OIT is a method to increase the amount of peanut that a child can eat before experiencing a reaction, helping to protect children against accidental contamination. Children receiving peanut OIT eat a gradually increasing amount of peanut over time until they reach a "maintenance" dose that is eaten regularly, even after the treatment, to help keep up the benefits. 

While peanut OIT can help children with peanut allergies to build protection, current approaches use large doses that require lengthy treatment, close medical supervision and often can result in discontinuation due to dislike of the taste and side effects of allergic reactions like anaphylaxis. 

The study is the first of its kind to compare a commonly used peanut OIT treatment to reduced doses in children, and provides evidence to support a significantly lower dose that could increase treatment accessibility and help protect more children with peanut allergy. 

A very little goes a long way 

To investigate the safety and effectiveness of a very low maintenance dose of peanut OIT, the study, published in the Journal of Allergy and Clinical Immunology – In Practice, randomly assigned 51 children with peanut allergy to three groups: low-dose treatment (30mg maintenance), standard-dose treatment (300mg maintenance) or avoidance (no peanut OIT). 

Both peanut OIT treatment groups experienced significant and similar increases in their allergic reaction threshold to peanuts, showing that eating even small amounts is better than avoidance when it comes to training the immune system to manage more peanut. 

"We were excited to find that peanut OIT maintenance doses can be much lower than previously thought and still contribute to positive outcomes," says Dr. Julia Upton, Head of the Division of Immunology & Allergy, Project Investigator in the SickKids Research Institute, Co-Director of the SickKids Food Allergy and Anaphylaxis Program and co-first author.

The more options we have, the more we can support patients' experience and provide meaningful, tailored care."

Dr. Julia Upton, Head of the Division of Immunology & Allergy, Project Investigator, SickKids Research Institute 

Children who were in the 30 mg maintenance group had fewer adverse reactions than the 300 mg maintenance group, and none withdrew from treatment. 

"This is a small enough dose that even children who do not like the taste can continue treatment," says co-senior study author Dr. Thomas Eiwegger, Adjunct Scientist in the Translational Medicine program. "This is the first time we've compared standard doses to such a low dose, but the minimum maintenance dose to provide benefit may be even lower than 30mg." 

The research team notes that some children and families may choose to remain on very low doses, while others may prefer to increase over time depending on their goals. This study marks an important step to further the development of safe and effective protocols for peanut OIT. Ultimately, the goal is to make peanut OIT accessible to more peanut-allergic children. 

"The study found that very small amounts of peanuts, that are associated with less reactions, could be used as effectively as large amounts for oral immunotherapy, making it safer and accessible to more Canadians, even those who are very sensitive to the allergen," says Dr. Moshe Ben-Shoshan, co-senior author of the study, a pediatric allergy and immunology specialist at the Montreal Children's Hospital and Scientist in the Infectious Diseases and Immunity in Global Health Program at the Research Institute of the McGill University Health Centre.