The Health and Economic Outcomes of Peanut Allergy Management Practices

Publication date: Available online 8 May 2018
Source:The Journal of Allergy and Clinical Immunology: In Practice
Author(s): Marcus Shaker, Matthew Greenhawt
BackgroundPeanut allergy is managed with strict avoidance, epinephrine carriage, and promptly treating reactions.ObjectivesAssess the health and economic benefits of pre-emptively injecting epinephrine for peanut ingestion in the absence of any symptoms, and avoiding products with peanut precautionary allergen labeling (PAL).MethodsWe used Markov modeling and simulations, assuming a base-case 10-fold fatality risk increase for less conservative management, with sensitivity analysis investigating 100-1,000-fold increased fatality risk, incorporating risks of accidental exposures, reactions, fatality, and family costs of food allergy. Using low-dose threshold challenges was evaluated to exclude subjects highly reactive to PAL items.ResultsBased on these assumptions, small reductions in per-patient fatality risk resulted from pre-emptive epinephrine injection without symptoms present (1x10^-4 fewer per-patient fatalities), with incremental costs of $1,193 per patient, $11,681,501/life-year saved, and $110,270,820/death prevented vs. waiting for symptoms before use, but this was not cost-effective even assuming 1000-fold risk ($107, 971/QALY) or quality of life (QoL). There were small reductions in per-patient fatality risk (1.7 x10^-4 fewer per-patient fatalities) for PAL avoidance vs. universal PAL consumption, with incremental costs of $3,342.05 per patient, $19,325,994/life-year saved, and $182,434,277/death prevented vs. allowing PAL consumption. PAL avoidance was not cost-effective when assuming 1000-fold risk or considering QoL. Incorporating a single, supervised low-dose challenge of 1.5mg of peanut protein to exclude children reactive to PAL consumption was cost-effective.ConclusionsCommonly recommended practices of pre-emptive epinephrine injection in the absence of symptoms, or universal avoidance of PAL were not cost-effective when compared with administering epinephrine upon symptom development or allowing PAL consumption.