Avacopan is Not Used for Peanut Allergies
Avacopan (also known as Tavneos) is a complement C5a receptor antagonist approved for treating ANCA-associated vasculitis, not peanut allergies. There appears to be confusion in the question, as avacopan has no role in food allergy management 1.
Current Standard of Care for Peanut Allergy
Primary Management Approach
The cornerstone of peanut allergy management remains strict allergen avoidance combined with emergency preparedness, including an anaphylaxis management plan with ready access to injectable epinephrine 1, 2.
- All patients with confirmed peanut allergy must carry an epinephrine auto-injector and receive training on recognition and self-treatment of allergic reactions 3
- Uncontrolled asthma is an absolute contraindication to any form of oral immunotherapy 1
FDA-Approved Treatment Option: Palforzia (AR101)
Patient Selection Criteria
Palforzia is the only FDA-approved drug for peanut allergy, indicated for children aged 4 to 17 years to mitigate the risk of allergic reactions from accidental peanut exposure 1.
- The European Medicines Agency also approved Palforzia in December 2020 for the same age group 1
- Efficacy was not demonstrated in patients 18 years or older in phase 3 trials 4
Treatment Efficacy
In the pivotal PALISADE trial, 67.2% of patients aged 4-17 years treated with AR101 (300 mg daily maintenance) could tolerate ≥600 mg of peanut protein without dose-limiting symptoms, compared to only 4.0% receiving placebo (P<0.001) 4.
- 62% of AR101-treated patients tolerated ≥1043 mg of peanut protein versus 0% of placebo patients 5
- Treatment reduced symptom severity during accidental exposures 5, 4
Safety Profile and Adverse Events
Gastrointestinal symptoms are the most common adverse events, occurring in 66% of AR101-treated patients versus 27% of placebo patients during buildup 5.
- During buildup phase: 10% experienced systemic reactions, 4% required epinephrine 6
- During maintenance phase: 19% experienced systemic reactions, 11% required epinephrine 6
- 21% of patients withdrew from treatment, primarily due to recurrent gastrointestinal adverse events 5
- Approximately 1% developed eosinophilic esophagitis during treatment 6
Critical Treatment Requirements
Patients on Palforzia must continue strict peanut avoidance and daily dosing to maintain protection—this is desensitization, not tolerance 1.
- Treatment requires Risk Evaluation and Mitigation Strategy (REMS) certification for pharmacies, healthcare providers, and clinics 7
- Patients must continue carrying epinephrine auto-injectors despite treatment 2
Alternative Immunotherapy Approaches
Epicutaneous Immunotherapy (EPIT)
The Viaskin Peanut 250-mg patch showed efficacy in children aged 6-11 years (50% responders vs 25% placebo, P=0.01) but not in adolescents or adults 1.
- Adverse events were predominantly mild local reactions at the patch site (98.2-100% of treated patients) 1
- Overall adherence was 97.6% after 12 months 1
Sublingual Immunotherapy (SLIT)
SLIT for peanut allergy shows moderate efficacy with lower side effects limited to oral mucosal symptoms, but interpretation is limited by reduced adherence over time 1.
- Lower baseline peanut-specific IgE (Ara h 2 and Ara h 3) predicts better treatment outcomes 1
Regional Guideline Variations
United States Approach
The 2014 Joint Task Force Practice Parameter recommends absolute avoidance and epinephrine preparedness, though off-label oral immunotherapy is widespread in private practice 1.
European Approach
EAACI guidelines restrict immunotherapy to research centers or clinical centers with substantial experience due to safety concerns regarding anaphylactic reactions 1.
Australasian Approach
ASCIA currently recommends against OIT for food allergies, citing concerns about high reaction rates and the need for additional studies on safety, tolerability, and long-term outcomes 1.
Predictive Factors for Adverse Events
Increasing pretreatment peanut-specific IgE levels are associated with increased odds of systemic reactions during both buildup and maintenance phases 6.