Setting Individual, Tangible Goals in Allergy Care

The delicate balance of dosing strategies for food allergy immunotherapy requires clear, concise instruction and frequent patient monitoring.

But before it can even be initiated, patients need to be gauged for their goals.

In an interview with MD Magazine® while at the American College of Allergy, Asthma & Immunology (ACAAI) 2019 Scientific Meeting in Houston, Whitney Morgan Block, MSN, CPNP, FNP-BC, president, chief executive officer, and co-founder of the National Allergy Center (NAC), and Teresa Neeno, MD, fellow NAC co-founder, discussed the value of tangible treatment goal-setting, and the shared value of the LEAP trial findings.

MD Mag: How can allergists assess and work toward tangible, individualized treatment goals with patients?

Neeno: That's really kind of the push at the meeting—is this shared decision-making, so that you know everyone's at the table and we're all deciding on this course of action that we're going to take, and getting a patient’s input.

Block: I mean, numerous research trials have definitely shown if somebody has written instructions, they're going to they're going follow it, they're going to be more compliant with it than open-ended.

And that’s even though when I started practicing, it was ‘incorporate it in part of the diet.’ That is super interpretable. Incorporating it in part of the diet for somebody that absolutely hates the food probably means, ‘Okay, I'll maybe eat it if I'm forced to.’

But incorporating in part of the diet for a bunch of allergist is more on a regular basis, and we've got to actually define what a regular basis is. Otherwise, patients are not going to know, and that's the reason why we have to have these studies. And all I can tell a patient is, ‘We don't actually know.’

In the LEAP study, it’s incorporated 2-3 times per week. Was that the correct dose, per se? Could you have done it less frequently? Should you have done it more frequently? That wasn’t a dose-finding study. We haven't done a dose-finding study so you could determine how low can you go. All we know is that the LEAP study worked and had amazing results.

Neeno: So the LEAP study is the Learning Earlier About Peanut trial—I don't know if you know that, but it looked at the differences between kids in Israel and kids in the UK, and looking peanut allergy in the same genetic populations, but different incidence of peanut allergy.

And the big difference was timing of incorporation of peanut into the diet. So, in Israel they have these bamba snacks that are kind of like Cheetos, but they have peanut on the outside and babies eat them.

Block: Yeah, it was pretty dramatic results. They separated the kids into 2 groups—one was skin test-positive to peanuts, and one was skin test-negative to peanuts. And we thought that the kids that were skin test-positive might be more likely to develop a peanut allergy.

And so within each of those groups, they told half of them to avoid peanut, and half of them to incorporate in the diet—and actually specifically gave them instructions. Most of them used bamba, but I think they actually have a choice of mamba and peanut butter. They had the goal of 2 grams of peanut protein at least 2-3 times a week.

Neeno: So, 2 grams is about 8 peanuts—which, for a little person, that's a pretty big quantity. But doable.

Block: Peanut butter is the most concentrated form of peanut. So, it's definitely doable to get into the diet. And what they found is that the people that were at the high risk, if they were in the incorporate peanut group, they were 8 times less likely of having a peanut allergy at age 5—which is awesome, because I mean, age 5 you're going to kindergarten. You're going be out at school and stuff like that.

So, we don't want kids to be restricted in any way, shape, or form, obviously. And just the less anxiety from the parents, the less worry that everybody's going have and the more freedom that the kid has. And they're not going to have to ask for things, and they're not going to have to be worried themselves.

It was a definitely huge landmark study. Everybody should know about it—not just in the allergy world—but in primary care world, too. Everybody needs to, because that really would change the entire thought about prevention and about incorporating foods in baby’s diets: when we should incorporate them, when we should introduce them. And it's something that everybody should know. I don’t understand why everybody doesn't know it yet.