For Children With Peanut Allergies, F.D.A. Experts Recommend a New Treatment | Hacker News Reader

For Children With Peanut Allergies, F.D.A. Experts Recommend a New Treatment

nytimes.com

44 pointspseudolus49 comments

> In July, the Institute for Clinical and Economic Review, a nonprofit research organization in Boston that evaluates medical evidence, concluded in a report that there was inadequate evidence to justify the immunotherapy treatment over simply avoiding peanuts.

To save you some time reading the report, this is because the quality-of-life results that they normally use to measure effectiveness weren't published in time. Their rating of the evidence is "promising but inconclusive".

This is not new. It's new that it has a brand name, but there have stories released repeatedly about exposure therapy for some time.

Based on previous articles on the subject, the only brand name I associate with peanut allergy is Bamba.

https://en.wikipedia.org/wiki/Bamba_(snack)#Peanut_allergy

It’s news in that it’s taking a step toward being available to real people. The previous stories you’re talking about were about research studies, not drugs available to the public.

The “drug” is just purified peanut protein. Comparable treatments have been offered by allergy specialists for a while and not just in the context of clinical studies.

If it’s FDA approved, it’s a pretty big step forward. Previously-available desensitization therapies for food allergies (OIT, SLIT) are not FDA approved and thus are not covered by insurance.

It's measured peanut flour. This sound like yesterdays $200 sling. I understand the lab setting, and administration should be expensive, but letting a company patent ground up peanuts weighed and in a capsule sounds a bit insane.

Insurace covers many procedures that are not FDA approved because they don't require special drugs or devices. Covering OIT with unapproved peanuts would probably be cheaper than OIT using this $4000/year peanut extract.

Insurance doesn’t cover OIT. Perhaps they will once it’s actually a cheaper option vs the FDA approved treatment that they’re eventually required to cover. Currently they simply decline to cover it at all because there is no downside to them.

But the reason cannot be simply that they "are not FDA approved and thus are not covered by insurance" given than many non-FDA-approved things are covered. They could cover them already (and they would if they thought ER visits would be reduced as a result). And as far as I know some insurance plans do actually cover these treatments.

1. Yes, they could hypothetically cover whatever they want beyond what is required by law. They don’t cover food allergy desensitization because covering it costs money and denying it has no downside for the insurance companies.

2. What non-FDA approved treatments are typically covered?

1. Anaphylactic shocks also cost them money. And they can also limit access to drug-based treatments if they don’t find them justified.

2. Tonsillectomy, physiotherapy... are you really unable to come up with some examples of surgical procedures and other physical and mental therapies not based on drugs?

You’re right. The limit isn’t just FDA approval. OIT and SLIT have, to my understanding, no medical approval of any meaningful sort. It’s an extremely early treatment (relatively speaking) and considered experimental.

Of course it's not new. The FDA will not make recommendations if a treatment is not tested thoroughly.

« The drug itself consists of peanut flour. »

....yep.

The Western World, and the US in particular, needs to take a long hard look at why allergies are so prevalent there compared to the East. I am from India, and while allergies are not unheard of, they are also pretty rare. I went through 15 years of schooling without anyone in my class ever having anything like an anaphylactic shock. Compare that to the hysteria about peanuts in my kid's school in the US.

To be clear I am not blaming the school. If there are kids with deadly allergies towards everyday foods, yes, there will need to be strong precautionary measures, but it's insane that we consider this high prevalence of allergies as normal here in the US, despite strong evidence from other countries that this doesn't need to be the case.

With our son (born and raised in the US), we basically exposed him to common allergens from Day 1. We'd rub them against his lips or place a very small amount on his tongue, and so on. Occasionally put a small bit of peanut paste in his formula, a bit of shrimp once he was a bit older, and so on.

He's 7 now, and has so far exhibited no common allargies.

This isn’t a terribly helpful anecdote. There is plenty of ongoing research into why there are higher rates of allergies in developed countries.

I’m sure early exposure to allergens help (and is AFAIK recommended practice now) but other things play a part - I’m sure I saw some research recently suggesting that one reason developed countries have higher allergy rates is due to lower prevalence of parasitic worm infections.

The natural world is complicated.

I think peanut allergies are often linked with other allergies. It comes down to anti-nutrients, namely lectins I think? Lectins are in all seeds, so even if you don't react to say beans or wheat, you might react in a way you don't recognize as reaction. I was depressed for half my life until I accidentally discovered that leaving out all seeds would solve the depression.

I’m bothered that medical research has seen influence by the MBAs. Ie. we don’t research looking for cures anymore because then you’ll only sell the drug once. Instead research management therapy so that you can have lifelong customers that need your product (pill) daily for the rest of their life.

This is popular narrative, especially on message boards, but is there any evidence that drug researchers are somehow biased towards medications that manage rather than cure conditions? Or is it just that cures are harder to discover than mitigations?

If you look at a list of current blockbuster drugs, you'll find that they are not primarily lifetime scripts. For instance, the second best-selling drug of 2015, Gilead's Harvoni, cures Hep C in a couple months. Most anti-cancer agents, which dominate the blockbuster lists, are not taken permanently.

Humira, AbbVie's arthritis med, has topped the charts for years, and is taken long-term, but it seems unlikely to me that if AbbVie or some other pharma found a way to permanently cure arthritis that they wouldn't sell the hell out of that product.

Given a cure (not a "maintenance" drug), companies would "sell the hell out of" that product until there were no more customers; then the market would collapse and the corporation would go bankrupt. The medical market is slightly more "graceful" in that new customers enter the market each generation.

This is not "popular narrative", it's established economic reality for any good that can be either rented or sold.

Compare selling vs renting a software package. Once a market is saturated no more sales can be made and the seller's company will likely collapse. In contrast, a renter collects each year until the software is superceded (but can add improvements each year to postpone that) or no longer useful.

I once worked for a company that sold a software package for a one-time (large) purchase fee plus a trivial annual maintenance fee. The employees walked the halls puzzling "What happens when we sell our last package?". Answer: company saw the light and tried to change from a purchase model to a rental model. All customers revolted and some threatened to sue (for software support ad infinitum). The company collapsed. Luckily I was gone by then.

And yes, the MBAs are responsible largely: they do good b/c they can tell you what business model to use to achieve your goals. Few industries are more concerned about how to make money than the pharmaceutical industry:

https://duckduckgo.com/?q=business+models+for+pharmaceutical...

But we also need corporations that are willing to develop true cures instead of "managements". Most MBA's aren't interested in that; maybe government can help by providing better incentives.

That's all great, but we're not talking about software, and you haven't addressed your parent poster's point in the slightest.

Of course someone could prioritize "management". That's not interesting. Interesting is the question whether they actually do, and you cannot argue that from first principles, philosophy-style. You need observations, news reportings, whatever. But facts, not "I could imagine...".

Admittedly I don’t have a resource to site. A quick google is easy to find all sorts of ways that the pharma industry has performed with their interests taking precedence over patients (eg price gouging, selectively publishing research). But, yes it’s proving to be a little hard to find specific details that show the industry prioritizes research that yields long term use drugs over cures.

To counter your point the existence of short term (& high cost) drugs doesn’t contradict that research prioritizes medications that maximize profit not patient lifestyle.

That's not evidence. Here's some evidence --- it's not dispositive, but it's more compelling than "this is how it seems like the pharma industry would act based on their other behavior" --- more dollars are spent on research on combating malignant neoplasms than on any other condition, and the most lucrative anti-cancer drugs tend not to be lifetime prescriptions. Both statements are easily confirmed with Google.

But it's also not responsive to the original argument, which is that MBAs have directed researchers to discover only mitigations and not cures to disease --- that the industry is actively avoidant of curative discoveries. That's an extraordinary claim.

it is good to see some progress with allergy treatment, especially peanut allergy. Many do not understand how having peanuts in the same room can cause allergy, so it is difficult to avoid it.

Yeah, I heard same room it can cause a reaction. I know a stake house we go to usually has them at the table, but last time didn’t have any. Seen someone else with some though, so apparently you can still ask for them. Probably done because of allergy concerns. Seems odd allergies seems more common than it used to be. I know I seen on the news one night they recommend introducing peanuts to babies earlier now.

I've heard more than once that its related to living conditions being so much more clean / sterile than they used to be. If you don't come across different substances regularly, your body has a hard time determining whether they are good or bad and is more likely to react when it finds them.

There is also a more specific hypothesis, that allergies are caused by the parts of the immune system that would normally be fighting off parasites.

There are a number of theories, this amongst them. There is also a connection to atopic dermatitis, which causes a skin barrier issue that allows proteins to pass.

https://www.nih.gov/news-events/news-releases/scientists-ide...

Allergy fear causes parents to not introduce peanuts at a young age and the lack of exposure causes peanut allergy. In Israel there is a peanut snack that children eat beginning very young. They have not seen the same uptick in peanut allergies.

Haha yeah it’s called Bamba, it’s a very delicious snack and my parents said they would let me eat a bunch of it when I was younger for this very reason. You can get it in the states.

I've seen it in Trader Joes. Its nice but I got bored of it quite quickly.

We introduced peanuts at a very early age. No impact. Our daughter had no allergies. Our son has an extreme peanut allergy. Based on this experience, I don’t believe early introduction helps.

How did anecdotal evidence of two individuals change your stance on advice based on proper, large scale research and international teams of subject matter experts? There is no claim being made that allergies can be prevented for sure, merely that early introduction to allergens significantly reduces the risk.

The American Academy of Pediatrics now recommends introducing children to peanut at an early age: https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages...

It's slowly becoming the accepted norm worldwide. In the Netherlands the (very recent) advice is to start with eggs and peanuts (in the form of pure peanut butter) from four months on.

Further reading: https://en.wikipedia.org/wiki/Hygiene_hypothesis

That can't be the only explanation, my first allergic reaction was at half-hour old (yes, at 30 minutes old), still have a scar from that on my face... ('What fight gave you that one?' 'Oh, the usual, formula milk as a newborn...') Though I suspect I'm still 'lucky' to only get rashes and 'hay-fever' reactions...

Funny story, 32 years later I'm still allergic to lots of stuff (food, plastics, heat), a couple of years ago I was so sick of it I forced my GP to have me tested. (It was forced because he was of the opinion that we knew I had allergies, so testing for a known outcome wouldn't tell us anything.)

He called me back asking why I was still alive... According to the results they found traces of a raging nut and peanut allergy (and other stuff some of which they didn't bother specifying further). So why am I still alive? I can't stand the smell nor taste of them, and they 'only' give me rashes and during accidental ingestion swollen lips/tongue...

>>I can't stand the smell nor taste of them

From what I know it is common to not stand the smell and taste of what you are allergic to. When a child really refuse to eat something it can be an idea to get it tested for allergy, since it unconscious can be because of how their body react to it.

I once shook hands with a new acquaintance who, unbeknownst to me, had just been snacking on a few peanuts at a bar: https://photos.app.goo.gl/7tvD65JmV45M4Mpw5

A handshake? Well that's me educated today. I'd always presumed food allergies required you to eat the problem food.

I don't think I have ever, not once, seen a media piece on allergies point out that eating isn't always required. That seems like a major failing in the reporting of allergies over the years.

Peanut allergy is often linked to pollen allergy, and peanuts can be pollen "bombs". So no need to eat it to get a reaction

Same here. I was quite surprised by the anecdote in the article about the person going into anaphylactic shock after having milk spilled on her hand.

In fact the skin reaction is utilized for allergy testing: https://en.wikipedia.org/wiki/Skin_allergy_test

Now those I knew of, but they mostly use a pin prick or scratch, and then measure the reaction and swelling in the skin. Which if anything, reinforces the misunderstanding the allergen needs to get into the system directly. Though I hadn't encountered the patch tests wikipedia mentions.

The article and mention of handshake leave me with an entirely different impression of how careful I might need to be if I started in food preparation etc.

I went to school with someone that was dating someone with nut allergies. She mentioned if she ate nuts at all during the day and kissed him at the end of the day he'd start having a reaction and swell up. She couldn't eat nuts for the day if she was going to see him.

That's not just peanuts. Unfortunately essentially any allergy can be so severe that airborne particles are a problem. I met a kid who was so allergic to egg that he literally went into anaphylaxis when his parents cooked some.

Soooo, kind of like homeopathy?

In the broad, pedantic sense... yes! This is literally homeopathy, with "like cures like". So are vaccines.

...but no, not in the common sense. :-)

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