"The largest food allergy study done to date": AR101 powder for peanut allergy

Tom Casale on oral immunotherapy for peanut allergy by Aimunne:

The new oral immunotherapy drug (AR101) helps build tolerance to the peanut allergy in the body, which could potentially lessen the severity of symptoms during an emergency. However, AR101 is nothing more than peanut powder - nothing fancy.

The PALISADE study was published in the New England Journal of Medicine (NEJM). AR101 is one step closer to becoming the first FDA-approved treatment for protecting against accidental exposure to peanuts in children who are allergic to them.

“This is the largest food allergy study done to date,” said Dr. Thomas Casale, an allergist and immunologist with USF Health. “It is very likely this drug will be approved by the FDA, given the results we’ve had so far.”

The AR101 drug was developed by Aimmune Therapeutics and manufactured in Clearwater. Casale is a member of the company's scientific advisory board.

AR101 contains precisely measured amounts of powdered peanut protein in pull-apart capsules, which was mixed in food and taken by patients with peanut allergies. These patients were monitored by physicians over the course of more than two years, as the amount of peanut was gradually increased.

USF was one of 66 sites across the United States, Canada and Europe that tested the drug. AR101 isn’t meant to “cure” a patient of their allergy, but to provide a safety buffer in case of an accidental exposure, Casale said.

“It’s not like these people can go to a Tampa Bay Rays game and eat a bunch of peanuts,” Casale said. “But they are protected from accidental exposure.”

The only way to prevent allergic reactions to peanuts and most other food allergies currently is to avoid them.

Aimmune Therapeutics plans to file for FDA approval before the end of this year. If approved, the drug could be available for use in children ages 4 to 17 by late 2019.

References:

https://www.tampabay.com/news/health/good-news-for-kids-with-peanut-allergies-a-new-drug-could-ease-symptoms-20181118
https://www.nejm.org/doi/10.1056/NEJMoa1812856

Pineapple food allergy is reported but medical literature evidence is limited

Pineapple food allergy is uncommon but it is still reported occasionally. There is an old case series in PubMed from 1993: https://www.ncbi.nlm.nih.gov/pubmed/8511816

Pineapple allergy could be due the following:

- the fruit allergen itself
- pineapple extract bromelain, including exposure at factories producing the extract (https://www.ncbi.nlm.nih.gov/pubmed/498486). This is called occupational exposure.
- cross-sensitivity with pollen. This is called oral food allergy syndrome.

Intolerance to pineapple is commonly reported but food allergy is more difficult to prove. Localized symptoms such as mouth tingling could be caused by local irritation caused by the acidity or the texture of the fruit. This is a nonspecific reaction, not related to food allergy.

Table 4 here lists the self‐reported prevalence of secondary FHS (pollen related fruits and vegetables) in 141 participants, thus 141/192 with possible pollen allergy reported secondary FHS to different fruits and vegetables. Kiwi allergy was reported in 7.8% of the participants followed by hazelnut (6.6%), pineapple (4.4%), apple (4.3%), orange (4.2%), tomato (3.8%), peach (3.0%) and brazil nut (2.7%). Reference: https://onlinelibrary.wiley.com/doi/full/10.1111/j.1399-3038.2008.00842.x

Cross-reactivity with latex was demonstrated in a study with latex-allergic patients, where 19% exhibited IgE antibodies to pineapple, as demonstrated by the Phadia ImmunoCAP® System. However, sensitization does not mean clinical allergy.

Cross-reactivity has been reported to occur between apricot, avocado, banana, cherry, chestnut, grape, kiwi, papaya, passion fruit, peach and pineapple. Kiwi fruit, papaya, avocado, pineapple, fig and banana may be associated with sensitisation to Ficus benjamina allergens.

The review of literature available as of 2018 does not provide solid evidence of food allergy to pineapple beyond the 1993 study and the self-reported symptoms. There is a paucity of case reports of pineapple allergy proven with sIgE, skin prick test and ingestion challenge.

Additional reading:

http://www.phadia.com/Products/Allergy-testing-products/ImmunoCAP-Allergen-Information/Food-of-Plant-Origin/Fruits/Pineapple/

6 endotypes of chronic rhinitis

6 endotypes of chronic rhinitis with different inflammatory patterns, which may help in delivering individualized treatment:

1. 38.6% were diagnosed as allergic rhinitis (AR) without asthma, with positive results for local eosinophils and high levels of local and serum IgE.

2. 13.5% as AR with asthma, with positive results for local eosinophils and high levels of local and serum IgE.

3. 18.6% were diagnosed as nonallergic rhinitis with eosinophilia syndrome (NARES) without asthma, with positive result for local eosinophils, and negative results for both local and serum IgE.

4. 4.6% were diagnosed as local allergic rhinitis (LAR) and showed positive results for local eosinophils and local IgE, but negative results for serum IgE

5. 5.0% as NARES with asthma, with positive result for local eosinophils, and negative results for both local and serum IgE.

6. 19.7% were diagnosed as idiopathic rhinitis (IR) because of high symptoms scores, but negative findings for local eosinophils, local IgE and serum IgE.

References:

Endotypes of chronic rhinitis: a cluster analysis study - Meng - - Allergy - Wiley Online Library https://buff.ly/2RgdUwO

Educate patients and public with AAAAI allergy chat on November 14

From AAAAI:

"Help Us Educate Patients During the AAAAI and Allergic Living Holiday Twitter Chat. Join us November 14 at 12:00 pm ET with the hashtag #allergyready to engage with families who want to learn more about allergies and asthma. Topics will include holiday visits, surprising triggers and winter asthma issues."

RSVP here:

https://www.allergicliving.com/2018/10/23/rsvp-to-the-holiday-twitter-party/

Local allergy societies may consider organizing similar Twitter chats.

Earn CME Credits for Time You Spend on Patient Research/Online Search - free if you are AAAAI member

New from the AAAAI: Earn CME Credits for the Time You Spend on Patient Research. You have to register for a course on the AAAAI website:

"How often are you faced with a patient care question that requires research? How often do you turn to the JACI or JACI: In Practice to find the answers to these questions? Would you like to earn credit for the searches you’re completing?

With the AAAAI’s Internet Point-of-Care Learning you can now earn 0.50 AMA PRA Category 1 CME CreditTM each time you seek the answer to a clinical care question in one of the AAAAI’s journals!

AAAAI Fellows and Members have free access to this member benefit
Non-members will be charged a $10 fee per use"

Return here to complete an unlimited number of Search forms to earn more credits for subsequent research efforts."

https://education.aaaai.org/IPOC2018#group-tabs-node-course-default3