Brian Vickery, MD: Food Allergy Guidelines' Role in New Therapies

Current food allergy treatment guidelines don’t recommend immunotherapy—the main practice of treatment currently being investigated by multiple drug companies for US Food and Drug Administration (FDA) consideration. That issue of inconsistency is among others Brian Vickery, MD, sees lining the current process of food allergy research and care.

In an interview with MD Magazine® at the American Academy of Allergy, Asthma & Immunology (AAAAI) 2019 Annual Meeting in San Francisco, CA, Vickery, Associate Professor of Pediatrics at Emory University and Director of the Food Allergy Center, Children’s Healthcare of Atlanta, advised caution and certainty in a time when the field of food allergy is heading towards previously unknown ground.

MD Mag: Are food allergy treatment guidelines updated to address current immunotherapy investigations?

Vickery: No. In fact, as they’re written now—there’s 2 guidelines. One was put out by the NIAID in 2010, and the other one was from the Joint Task Force on Practice Parameters—that one’s put out by both the academy (AAAAI) and college (ACAAI). And both of them say currently that immunotherapy is not recommended in the treatment of patients. That's what they currently say.

So, there's a bit of a disconnect there with where the field is right now in 2019. And a lot of people are talking about, should there be revision of those guidelines? Should there be issuance of new or different guidelines? If so, what should be in them? And I don't think there's a sort of a unified feeling about that right now.

My perspective is that, with the PALISADE data set, we now have by far the largest clinical trial in food immunotherapy. You have the most robust set of data on which you can you can make evidence-based recommendations for peanuts because of the strength of the study, and it had 550 individuals in 10 countries, 66 sites, randomized, placebo-controlled—a really rigorous study. You don't have that for the other foods. And I think this idea that, “Well, we've worked it out for peanut, so we now can apply those lessons to other foods,” is, I think a worrisome conclusion. Because my feeling is that there's ample evidence that other foods behave differently.

The natural history of diseases is different. There are multiple patient phenotypes that are different with say, milk. There’s some preliminary data from milk OIT studies that looks very different than peanut. So I would like us, as a field, to continue to evolve in an evidence-based direction, where we actually study these concepts with rigorous protocols and adapt our practices accordingly.

And there seems to be this kind of rush to move forward and treat patients, even despite the fact that we don't really know yet what we're doing, what dose is right, what regimen is right. We're off the map for a lot of these other foods and, as a scientist that sort of concerns me. And as a person who takes care of these patients, we know that they are dealing with a highly unmet-need condition. We know that they are desperate for solutions.

I see those patients in my clinic, and they're hungry for something better than what they have. That's why I do this kind of work. But that does not mean that we should do something without really understanding what it is.