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Peanut Allergy: Overview, Diagnosis, and Treatment
About Peanut Allergy
Peanut allergy is common, severe, and long-lasting.1-3 Unlike allergy to other foods, such as milk, egg, soy, and wheat, allergic sensitivities to peanut are rarely outgrown,1,3 and in fact, only about 20 percent of people with a peanut allergy outgrow it.4,5 Peanut allergy affects approximately 1 percent of the U.S. population.1,4,5 Reactions to peanuts frequently occur on the first known ingestion of the food.3 Recent research has also shown that children with peanut allergies can be desensitized to it by ingesting increasing amounts of peanut under close supervision.5
Peanuts, along with tree nuts, are responsible for the most serious allergic reactions and food-allergy related fatalities.1,5 Alongside tree nuts, peanut allergic reactions are the most common culprit of fatal food-induced anaphylaxis, with the greatest number of fatalities occurring in adolescents and young adults.6-8 Studies have shown an increased prevalence of tree nut allergy in individuals with peanut allergy.3
Progressive respiratory symptoms, hypotension, and arrhythmias typically develop in near-fatal cases and fatal reactions.8
20% of people
Only about 20 percent of people with a peanut allergy outgrow it.4,5
Making an accurate diagnosis when evaluating a patient with a possible peanut allergy is important to avoid unnecessary dietary restrictions and prevent life-threatening anaphylactic reactions.9
Peanut allergy: Refining differential diagnosis through testing
The typical route to diagnose peanut allergy begins with a physical examination and detailed medical history.8,9 The next step may include testing, such as specific IgE blood testing or skin-prick testing, that is used to support the diagnosis of peanut allergy and determine whether an oral food challenge should be considered.8-12 These key diagnostic tools are essential for arriving at an accurate diagnosis.9 Making an accurate diagnosis when evaluating a patient with a possible peanut allergy is important to avoid unnecessary dietary restrictions and prevent life-threatening anaphylactic reactions.9
Who should be tested?
Identifying individuals with peanut allergy is important, as these patients are at risk for severe reactions.1-3 As allergy to peanut is usually lifelong and accounts for most of the food-induced severe and fatal allergic reactions, the diagnosis of peanut allergy carries with it considerable significance medically and emotionally, as well as psychosocially and financially on patients and their families.8,13
Children with peanut allergy may be re-evaluated at regular intervals to determine whether they have achieved tolerance to peanut.5
The evaluation for a patient with a possible food allergy begins with a thorough history and physical exam. If the clinical history suggests an IgE-mediated food allergy, specific IgE tests are needed to help confirm the diagnosis.11
What is component testing?
What is component testing?
When a patient asks, “Do I have a peanut allergy?,” it’s tempting to get a “yes” or “no” answer and leave it at that. But what if there was a way to uncover even more information about an allergic sensitization, such as the specific protein that’s triggering your patient’s reaction?
If you have a patient sensitized to peanut, specific IgE blood testing for peanut components can help assess the risk of reaction severity, from mild and localized to severe, including the risk of anaphylaxis, or potentially no clinical reaction at all.16
So instead of just answering the question, “Am I allergic to peanuts?,” you can determine the exact proteins that trigger a reaction, and the risk of reaction severity and cross-reaction associated with that protein. Testing with allergen components can also help determine whether an oral food challenge (OFC) test is recommended. An OFC test can be used to confirm a food allergy or determine whether a patient has outgrown a food allergy.
By detecting sensitization with peanut component testing, you can create a personalized management plan for your patient.
Peanut allergy and quality of life
Food allergy, including peanut allergy, can have a dramatic effect on quality of life.14 Many studies have detailed the negative effect of food allergy on health-related quality of life (HRQoL), as well as the financial and emotional toll a food allergy takes.12 Identified issues include feeling different because of the diet, worrying about foods, the presence of physical and emotional distress, increased responsibility, effect on social activities (social restrictions, school, travel, and restaurants), anxiety, stress, bullying, and having to consistently exercise greater caution.12
Common foods that may contain peanuts
It is important for healthcare providers to educate patients on reading and interpreting food labels, as peanut can be an ingredient in many foods.15 A high level of patient education is needed to maintain safety when it comes to allergen avoidance.12
Possible hidden sources of peanut exposure include: 8
Nonfood sources containing peanut may include ant baits, bird feed, mouse traps, pet food, cosmetics, sunscreens, craft materials, medications, vitamins, mushroom-growing medium, and stuffing in toys.8
Co-sensitization to tree nuts and seeds are also common in peanut allergy patients.8
Testing Increases Diagnostic Confidence
Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv
i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238
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Management and care of patients with peanut allergy
Avoidance is the key to peanut allergy treatment and management, but it can be difficult to achieve as peanuts may be hidden in foods.17 Manifestations of peanut allergy may be life-threatening and require an aggressive approach to risk-factor modification and management, with emphasis on prevention and the use of injectable epinephrine.8
Management of peanut allergy is based mainly on:
1. Educating patients and their families to avoid peanuts and peanut-containing products.
2. Awareness of early signs of an allergic reaction resulting from exposure to peanut.
3. Education on the proper use of an epinephrine auto-injection kit.8
Practice parameters have been developed to help guide the management and treatment of patients with food allergies, including peanut.
Practice parameters and guidelines
for peanut allergy:
- Sicherer SH, Burks AW, Sampson HA. Clinical features of acute allergic reactions to peanut and tree nuts in children. Pediatrics. 1998;102(1):e6
- Sicherer SH, Muñoz-Furlong A, Sampson HA. Prevalence of peanut and tree nut allergy in the United States determined by means of a random digit dial telephone survey: A 5-year follow-up study. J Allergy Clin Immunol. 2003 Dec;112(6):1203-7.
- Maloney J, et al. The use of serum-specific IgE measurements for the diagnosis of peanut, tree nut, and seed allergy. J Allergy Clin Immunol. 2008;122:145-51.
- Fleischer DM. et al. Peanut allergy: Recurrence and its management. J Allergy Clin Immunol. 2004; 114 (5)1195 – 1201.
- Waserman S, Watson W. Food allergy. Allergy Asthma & Clin Immuno. 2011, 7(Suppl 1):S7
- Bock SA, Munoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001; 107:191–193.
- Bock SA, Munoz-Furlong A, Sampson HA. Further fatalities caused by anaphylactic reactions to food, 2001-2006. J Allergy Clin Immunol. 2007; 119(4)1016-1018.
- Al-Ahmed N, et al. Peanut Allergy: An Overview. Canadian Society Allergy Asthma Clin Immuno. 2008;4,139.
- Kattan JD, Sicherer SH. Optimizing the Diagnosis of Food allergy. Immunol Allergy Clin North Am. 2015; 35(1): 61–76.
- Kurowski K, Boxer RW. Food allergies: detection and management. Am Fam Physician. 2008;77:1678-1688.
- Burks AW, Tank M, Sicherer S, et al. ICON: Food allergy. J Allergy Clin Immunol. 2012;129:906-920.
- Sicherer SH, Sampson HA. Food allergy: A review and update on epidemiology, pathogenesis, diagnosis, prevention, and management. J Allergy Clin Immunol. 2018 Jan;141(1):41-58
- Wang J. The Evolving Science of Peanut Allergy. J Allergy Clin Immunol. 2019 Feb; 7(2)387-388.
- Antolín‐Amérigo et al. Quality of life in patients with food allergy. Clin Mol Allergy. 2016;14:4
- Mofidi S. Nutritional management of pediatric food hypersensitivity. Pediatrics. 2003;111(6 Pt 3):1645–53.
- Kattan JD, Wang J. Allergen Component Testing for Food Allergy: Ready for Prime Time? Curr Allergy Asthma Rep. 2013;13:58–63.
- Ewan PW. Clinical study of peanut and nut allergy in 62 consecutive patients: new features and associations. BMJ 1996;312(7038):1074-8.
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