Is it safe to administer Oral Immunotherapy (OIT) for peanut allergies twice daily versus once daily?

Safety of Twice-Daily Dosing in Peanut Oral Immunotherapy (OIT)

Twice-daily dosing for peanut oral immunotherapy is not recommended due to increased risk of adverse reactions compared to once-daily dosing protocols used in clinical trials and practice guidelines. 1

Current OIT Protocols and Safety Considerations

Oral immunotherapy (OIT) for peanut allergies is an emerging treatment approach that requires careful administration under medical supervision. The evidence shows that:

• Standard OIT protocols involve once-daily dosing with gradual dose escalation over months to years 1
• Patients in OIT trials have experienced anaphylaxis during both in-office and home dosing phases 1
• The risk of adverse reactions is highest during initial escalation days (46-79% of doses) but decreases significantly during home maintenance dosing (3.5% of doses) 2

Safety Risks of Altering Established Protocols

Modifying established OIT protocols by administering twice-daily doses could:

• Increase the frequency of adverse reactions, which commonly include upper respiratory symptoms, skin reactions, and gastrointestinal symptoms 1, 2
• Potentially lead to more severe reactions requiring epinephrine administration 2
• Disrupt the immunological mechanisms that require specific timing between doses for proper desensitization 1

Evidence from Clinical Trials

Clinical trials supporting peanut OIT have specifically used once-daily dosing protocols:

• The FDA-approved peanut OIT product (Palforzia) is designed for once-daily dosing with a maintenance dose of 300 mg peanut protein 1
• Studies demonstrating efficacy and safety of peanut OIT used once-daily dosing regimens 3, 4
• A Cochrane review found that even with standard once-daily protocols, there is "substantial risk of adverse events" 5

Practical Considerations

If a patient is considering OIT for peanut allergy:

1. OIT should only be performed under the supervision of allergists with experience in food allergy management
2. Adherence to established protocols is essential for safety
3. Patients must be equipped with emergency medication (epinephrine) and action plans 1
4. Uncontrolled asthma is an absolute contraindication to OIT 1

Alternative Approaches

For patients concerned about OIT protocols:

• Low-dose OIT (125-250 mg maintenance) has shown promising efficacy with potentially fewer side effects 4
• Premedication with antihistamines like ketotifen may reduce gastrointestinal symptoms during OIT 6
• Sublingual immunotherapy (SLIT) has fewer systemic side effects but may be less effective 1

In conclusion, altering established OIT protocols by administering doses twice daily rather than once daily introduces unnecessary risks without proven benefits. The current evidence supports maintaining the standard once-daily dosing schedule that has been evaluated in clinical trials and incorporated into practice guidelines.