Immunotherapy: In a Nutshell, Possible Treatment for Peanut Allergy

Deep-fried peanuts.
By Mr. Atoz. (CC BY-SA 3.0)

When our youngest daughter was a year old, we decided to introduce her to some more interesting table foods. One night at dinner, I gave her a spoonful of chicken cooked with ginger, soy sauce, brown sugar, and peanut butter. I thought she might protest. What I didn’t expect were swollen cheeks and husky breathing.

Minutes later, lights flashed in our driveway and half a dozen men in blue crammed into our living room to check our daughter’s vital signs. I was relieved, if a bit sheepish: No treatment was needed after all. But later tests revealed a mild to moderate peanut allergy, and so we joined the ranks of Epi-Pen-toting parents.

Currently there is no approved treatment for peanut allergy. As a result patients or their parents must carefully monitor diets and carry around lifesaving doses of epinephrine (used in cases of accidental ingestion to treat a severe allergic reaction, or anaphylaxis). However, a recent double-blind, multicenter study (reported here in The Journal of Allergy and Clinical Immunology) shows that sublingual immunotherapy might be a way to prevent allergic reactions.

Dr. Wesley Burks, professor and chair of pediatrics at the University of North Carolina School of Medicine and the study’s lead author (along with Dr. David Fleischer of National Jewish Health in Denver), discussed the results with me:

In 20 percent of cases, Burks explains, children who acquire a peanut allergy in the first years of life will eventually outgrow it. But it’s hard to predict who will leave the allergy behind, or what will be the severity of side effects. “There’s certainly anxiety inherent in a diagnosis because of the [uncertaity] of what future reactions might be like,” says Burks.

“The prevalence of peanut allergies has changed so much in the last two decades that it has become more important to find a treatment,” he adds. “Only recently though has [sublingual immunotherapy (or SLIT)] been used with appropriate dosing that could be used for peanut allergy.” (SLIT has previously been used to treat a range of allergies, from milk to peaches.)

SLIT works by desensitizing the patient to the allergen over time. In this study, patients were exposed over many weeks to tiny (and gradually increasing) daily doses of peanut powder in a liquid that was squirted into the mouth and held under the tongue for two minutes before swallowing. That time in the mouth is key, explains Burks, because mucous membranes there give the allergen rapid entry into the body’s immune system.

(Subcutaneous immunotherapy, which uses injections, is another treatment option for some kinds of allergies, but it has not been found to be safe in the case of peanut. According to Burks, studies were stopped in the 1990s because of significant side effects.)

At the beginning of the SLIT study Burks took part in, 40 subjects with peanut allergy were given an oral food challenge of up to 2 grams of peanut powder to see how much they could tolerate. Then subjects were randomly assigned to receive either peanut SLIT or a placebo. At the end of a 44-week period, the patients were given another food challenge. Those who could safely consume 5 g, or at least 10-fold more peanut powder compared to their baseline, were considered “responders.” In the SLIT group, 70 percent were responders, compared to just 15 percent of the placebo group. Among responders, the median consumption of peanut powder rose from 3.5 to 496 milligrams. Following 68 weeks of treatment, median consumption climbed to 996 milligrams, or about the equivalent of three peanuts.

That doesn’t sound like much (and indeed, immunotherapy is no invitation to start snacking on Snickers bars). But it’s significant to allergy sufferers. According to Burks, an allergic reaction typically happens to less than one third of a peanut. (Trace amounts can find their way into foods prepared in factories, kitchens, or restaurants where peanuts are used. “In theory, you could take a daily dose and it could protect you from most accidental interactions,” he says.

“What we don’t know is the dosing ranges and how long to treat someone to make it permanent—or even if we can make it permanent,” Burks adds. “What needs to happen are more studies, using more people, in different dosing regimens.”

Diseases of the Mind: A Flawed, Innovative 19th-Century Guide to Mental Illness

 

Portrait of Dr. Benjamin Rush by Charles Willson Peale (1741-1827). Wikimedia Commons.

 

Two hundred years ago, American physician Benjamin Rush published his extensive guide to the diagnosis and treatment of mental illness, Medical Inquiries and Observations Upon Diseases of the Mind. Before Rush’s time, there was little knowledge on how to care for mentally ill patients. In fact, when Rush joined the staff at Philadelphia’s Pennsylvania Hospital in 1783, there were two dozen “lunatics” (to use the parlance of the day) kept in unheated basement cells. Rush argued for their comfort and worked to improve their living conditions. But many of his recommended therapies would seem strange, and even inhumane, to the 21^st century reader.

In an article I wrote for The Pennsylvania Gazette, I interviewed contemporary therapists about Rush’s complex legacy to the mental-health field:

“It really is a mix of things,” says Robert DeRubeis, chair of the psychology department at the University of Pennsylvania. Diseases of the Mind includes treatments that therapists “would never do today” because they’re inhumane, ineffective, or theoretically unsound. “They range from alarming to eyebrow-raising to bemusing when you read about them,” DeRubeis says. “But then there are another set of treatments he describes that are perfectly sensible—some of which are in quite widespread use today and some of which should be in more widespread use.”

In Benjamin Rush: Patriot and Physician, biographer Alyn Brodsky writes that, as flawed as it was, Diseases of the Mind “was so complete and so unique a study of mental diseases that it remained the only comprehensive American study on the subject for seventy years, and was the foundation upon which superseding studies incorporating scientific advances were based.” Brodsky adds, “We can attribute to Rush’s efforts more innovation in the hospitalizing and treatment—above all, the understanding—of the mentally afflicted than to any other physician of his time.”

Below are just a few of Rush’s remedies for various afflictions. (Keep in mind the diagnosis terms are not ones in use today.) To find out what contemporary therapists at the University of Pennsylvania have to say about these and other therapies, see my sidebar in the Gazette.

For general intellectual derangement

Pennsylvania Hospital, William Strickland. Image in public domain due to age.

Confinement

by means of a strait waistcoat, or of a chair, which I have called a tranquilizer. He submits to them both with less difficulty than to human force, and struggles less to disengage himself from them. The tranquilizer has several advantages over the strait waistcoat or mad shirt. It opposes the impetus of the blood towards the brain, it lessens muscular action every where, it reduces the force and frequency of the pulse, it favours the application of cold water and ice to the head, and warm water to the feet, both of which, I shall say presently, are excellent remedies in this disease; it enables physician to feel the pulse and to bleed without any trouble, or altering the erect position of the patient’s body; and, lastly, it relieves him, by means of a close stool, half filled with water, over which he constantly sits, from the foeter and filth of his alvine evacuations.

Bloodletting

It should be copious on the first attack of the disease. From 20 to 40 ounces of blood may be taken at once, unless fainting be induced before that quantity be drawn. It will do most service if the patient be bled in a standing position. The effects of this early and copious bleeding are wonderful in calming mad people. It often prevents the necessity of using any other remedy, and sometimes it cures in a few hours.

Low diet, consisting wholly of vegetables, and those of the least nutritious nature

By Garelvirat. Flickr Creative Commons.

Cold, in the form of air, water and ice.

The hair should be cut off, and shaved from every part of the head … by cutting off, we not only expose the head to a greater degree of cold, but we favour by it, at the same time, depletion from the brain, by means of insensible perspiration.

Cold water should be applied … to the head … by means of cloths, or a bladder, to which ice, when it can be obtained, should be added … The coldnesss should be frequently renewed, and they should be continued for several days and nights. The signal for removing them should be, when they produce chilliness, and sobbing or weeping in the patient.

In order to derive benefit from the application of cold water to the whole body, it should be immersed in it for several hours, by which means we prevent the re-action of the system and thus render the sedative effects of the water permanent.

For hypochondria

Destruction of the old association of ideas.

Every thing a hypochondriac patient sees or hears, becomes tinctured with some sad idea of his disease … Change therefore his dress, his room, his habitation, and his company, as often as possible.

Employment, or business of some kind.

Man was made to be active. Even in paradise he was employed in the healthy and pleasant exercises of cultivating a garden. Happiness, consisting in folded arms and in pensive contemplations, beneath rural shades, and by the side of purling brooks, never had any existence, except in the brains of mad poets, and love-sick girls and boys.

Cultivating a garden, 18th-century English woodcut.

Certain amusements.

These should be preferred, which, while they interest the mind, afford exercise to the body. The chase, shooting, playing as quoits, are all useful for this purpose. … Chess, checkers, cards, and even push-pin should be preferred to idleness, when the weather forbids exercise in the open air. The theatre has often been resorted to, to remove fits of low spirits;: and it is a singular fact, that a tragedy oftener dissipates them than a comedy… Certain animals suspend the anguish of the mind of this disease by their innocence, ingenuity, or sports.

Music has often afforded great relief in this disease. .. I attended a citizen of Philadelphia, occasionally in the paroxysm of this disease who informed me that he was cured of one of them by hearing the old hundred psalm tune sung in a country church ….

For manalgia

Exercise.

This should consist of swinging, seesaw, and an exercise discovered by Dr. Cox, which promises more than either of them, and this is, subjecting the patient to a rotary motion, so as to give a centrifugal direction of the blood towards the brain … I have contrived a machine for this purpose in our hospital, which produces the same effects upon the body … These are vertigo and nausea, and a general perspiration. I have called it Gyrator. … It produces great changes in the pulse. In one experiment made with it, it increased the pulse from 84 to 88 strokes in one minutes, and to 120 in two minutes.

Labour

has several advantages over exercise, in being not only more stimulating, but more durable in its effects, whereby it is more calculated to arrest wrong habits of action, and to restore such as are regular and natural. It has been remarked that the maniacs of the male sex in all hospitals, who assist in cutting wood, making fires, and digging in a garden, and the females who are employed in washing, ironing, and scrubbing floors, often recover, while persons, whose rank exempts them from performing such services, languish away their lives within the walls of the hospital.

For derangement of the passions (grief)

Opium

It should be given in liberal doses in its first paroxysm, and it should be repeated afterwards, in order to obviate wakefulness.

1743 gravestone – Church of St. Peter-in-the-Great Valley, Saint Peter’s Road (East Whiteland Township), Devault, Chester County, PA. Library of Congress.

Silent company

Persons afflicted with grief should be advised to receive the visits of their friends, of whom the physician should always be one … They should imitate the conduct of Job’s friends, who after weeping for his losses and afflictions when they beheld him afar off … “sat down with him upon the ground, seven days and seven nights, and none spake a word to him, for they saw his grief was very great.” … There is science, as well as sympathy in this silence, for in this way, grief most rapidly passes from the bosom of the sufferer into that of his friend.

Removal

The persons afflicted with grief should be carried from the room in which their relations have died, nor should they ever see their bodies afterwards. They should by no means be permitted to follow them to the grave. It would be useful to inter the body of the deceased as far as possible from the view of the person, who is the subject of grief … After the expiration of the weeks of mourning, care should be taken never to mention the names of the deceased persons to any of their friends, nor to allude to any thing that by means of association can revive their memory.