D3.214 - Flexible and Safe Oral Immunotherapy (OIT) Regimen Using Home Boiled Nut Broths (HBNB)

Nut allergy is outgrown in 9-20% of patients. Aside from peanuts, there are no FDA approved nut OIT products. Peanut OIT before the age of 4 years was associated with an increase in both desensitization and remission. The usual OIT protocols require strict dosing regimens, inaccessible to some patients. While glycation renders roasted nuts more allergenic, boiling can denature the proteins.

We present a series of four peanut/cashew OITs, some of which were conducted in patients who lived in different countries, initiated using HBNB. Parents were asked to boil 20 grams of respective nut kernels in 240 ml of water for 30 mins and add water to make the final solution 240 ml, which was used for initial doses of the OIT. Subsequently, the boiled nuts or the nut butter were used. To quantify the maximum possible concentration of the broths, we measured the protein concentration of the boiled ground nut broths. Consents for publication of patient data have been obtained.

The average protein concentrations of boiled ground nut broths were 22.5 mg/ml for peanuts, 18.35 mg/ml for cashew, and 45.5 mg/ml for peanut+cashew. IgE to peanuts, Ara h2, cashew, Ana o3 were: >100-204, 6.43 - >100, 32-141, 36-88 kUA/L, respectively. Age were 21 months to 15 years. One dose of epinephrine was used at the initial challenge. Initial home doses were from 8 drops to 15 ml. Intervals varied between 1-52 weeks due to the limitation of patient’s geographic location. Home dosing was held if patient was ill and resumed at home. Patients with bronchial hyperresponsiveness were maintained on controller. The reactions to home doses were infrequent, mild, and resolved spontaneously. No epinephrine was required. The duration from the first home dose was 10-19 months. The current tolerated dose for each OIT were 4 teaspoonfuls (tsp) of peanut butter (PB), 1/8 tsp of cashew butter (CB), ½ tsp of PB and CB each, and 1/64 tsp of PB for OIT1-OIT4, respectively. (See table).

Although the protein concentration from different lots of HBNB can vary, the approach of OIT initiated by HBNB is well tolerated. Home reaction was mild, and no epinephrine was needed.  Transition to nut butter or boiled nuts did not elicit a major reaction. Flexible updosing intervals of home prepared agents, and the ability to gradually resume the dose at home allows patients living in a different country to be able undergo OIT, as well as increasing adherence to the regimen and success rate.