As we enter a new era in allergy treatment with the release of the first Food and Drug Administration (FDA)-approved product to treat peanut allergy, I wanted to reflect on the recent history that made this day possible. Many studies, including LEAP, have shown that avoidance of peanuts in early life is the root cause of development of many cases of peanut allergy. Unfortunately, many health care providers continue to advise avoidance of peanuts “just to be safe.” A National Institute of Allergy and Infectious Diseases study to be published shortly that surveyed allergists showed they understood and used LEAP correctly.
We have all heard the rare reports of death from supervised oral food challenges. I'm sure we are all saddened, as even one death is too many. Since the 2011 National Heart, Lung and Blood Institute guidelines were issued, oral food challenges have become an increasing part of clinical practice. With the availability of an FDA-approved peanut oral immunotherapy, the need for oral challenges to confirm the diagnosis of food allergy increases.
I have heard many people say, in promoting the safety of oral challenges, that the risk is similar to that of immunotherapy injections. Since there is a small but measurable death rate from allergy immunotherapy, are rare deaths an inevitable outcome as the frequency of food challenges performed increases?
While we all agree one death is too many, we have all accepted the risk with allergen immunotherapy. It is the only treatment that modifies the immune system, altering the course of the disease.
Just like with immunotherapy injections, oral food challenges have changed the lives of thousands of our patients, proving they were not allergic and allowing them to live normal lives. With the availability of treatment, the oral challenge takes on an even more important role.
I've heard people say that because deaths can occur with oral challenges, we should suspend or even stop them. Others say we should limit them to those with low in vitro values, or otherwise at low risk. If we heed this advice, how many people will live in fear unnecessarily? Death from peanut anaphylaxis is extremely rare.
In too many circumstances, not using epinephrine for anaphylactic reactions seems be a source of unjustified pride or a badge of honor. The true epidemic we face is patients not getting epinephrine when needed, both in the field and under the supervision of health care providers. I am reminded of an incident when I was a pediatric intern. I had a patient who needed epinephrine and whose tetralogy of fallot had recently been corrected. The attending cardiologist politely (but firmly) told me to get off the phone and treat our patient for his life threatening allergy. He assured me he would “take care of it” if a cardiac problem occurred. His advice to me was wise.
Certainly, we need to learn from these unfortunate deaths, but retreating from what is proven to be the best course of action to avoid a rare complication could cause more people to needlessly suffer and even die. I am excited as our specialty crosses the threshold into a new horizon, taking the first step into an exciting future where food allergy can be treated.
J. Allen Meadows, MD, FACAAI