Edwin Kim, MD, Chief of Pediatric Allergy at the University of North Carolina School of Medicine talks about a toothpaste for people who have a peanut allergy.
Interview conducted by Ivanhoe Broadcast News in 2024.
Now because of planes and everything in schools, you’re hearing a lot about peanut allergies and it seems like more research is being done now than ever before to find ways to keep these people safe, right?
Kim: Absolutely. Peanut allergy is one of the allergies that’s probably the most prevalent and also leads to more severe type reactions. Unfortunately, it’s also one that most kids don’t outgrow. We in the allergy world have used that as our model allergen to try to understand what’s happening with it and then what things we can do to try to treat it.
Now, I’ve done some stories in the past about the powder that you would mix with food but that has drawbacks.
Kim: For sure, the powder is called oral immunotherapy, where we in a controlled way, have the patients, the kids, eat that peanut flour in small increasing amounts to try to retrain their immune system and make them less reactive. I think the key thing with that is we’ve proven that we can make a difference. We can change the immune system and protect these kids. But exactly as you said, what we’ve also learned at the same time is it can be difficult. First, difficult because of side effects, but then also difficult just to do with some of the limitations around timing. It’s made it important that we try to take what we’ve learned from oral immunotherapy and find easier and safer ways to do it.
First, tell me some of the side effects of the powder.
Kim: I think the key piece is we’re having these kids eat what they’re allergic to. Sure enough, what you can see is they can have allergic symptoms and even anaphylaxis, it could be as little as a stomachache and some rashes or hives, but it could be coughing, it can be wheezing, and it could be things that even require an EpiPen to be treated. Again, a high-risk, high-reward type of treatment.
But now there’s a toothpaste. Can you explain that?
Kim: That’s right. Again, trying to take the idea of we know that the small increasing exposures can change the immune system, but can we do it in a different way that might have better safety? What we know is there are immune cells throughout your mouth that can potentially, again, make someone less allergic and even possibly desensitized to that. To take advantage of it, one of the companies had decided, maybe we take the peanut and then put it in the form of a toothpaste that coats the whole inner side of the mouth. We can take advantage of those immune cells, and get the benefit that we want, but then use much smaller doses than what the kids are swallowing, that are eating, and maybe get better safety.
When you’re talking about the small dose of toothpaste, how much is that? Is that like a sliver of a peanut or how could people visualize that?
Kim: When we’re having the kids eat the peanut with the oral immunotherapy, kids are eating anywhere from one up to, in some cases, three to five whole peanuts every single day as a treatment. With the toothpaste, they are exposed to only about 1/75th of one peanut.
Have you seen reactions to this?
Kim: The most common reaction we have seen – we do a version of this at UNC using a liquid peanut extract that’s held under your tongue. Not the same as the toothpaste, but very similar in how it works. What we see is a lot of the folks do complain that they get an itching in the mouth. The nice thing there though, is it doesn’t seem to lead to anything more. Within about maybe 10 to 15 minutes, it goes away on its own. A lot of the patients, a lot of the kids get used to it. It doesn’t end up being a bother.
You do it every day, but how long do you do it until you start seeing, well maybe, they are lessening their allergies a little bit?
Kim: The way that we can tell when the treatment is working is we give them an oral food challenge. What that means is we have them come to the clinic and give them a pretty big number of peanuts to see if they react. But that comes with risk, and we can’t do that every single day. What we’ve tried to use is some labs, skin tests, as well as blood tests, to give us a sense of when the immune system is changing. Some of those tests have told us it looks like even as early as four or five months into the treatment, we’re starting to see some of that benefit. By the time they reach a year and longer, we’re seeing clear benefits and increases and how much peanut it takes to cause a reaction.
Does this mean if you continue to do this toothpaste or the drops underneath your tongue, in five years you’ll be cured of your allergy?
Kim: We are hopeful that the longer you use it that that benefit does continue to get stronger and stronger. Unfortunately, at this point in the studies we’ve done, we’ve not seen any of them that seem to lead to a cure. We do feel pretty good that we can get people to a pretty high threshold and protect them against any of those small unintentional exposures they might have. You mentioned the airplanes, at schools, things like that. But at this point, it does not look like these are going to lead to a cure. But again, we don’t know that for sure and that’s why the studies need to keep happening.
Does this mean my child goes to a birthday party and has a peanut butter cookie, that’s not what you’re trying to get to, you’re trying to get it so they don’t have a deadly reaction?
Kim: That’s right. There will be some kids that may get to thresholds that are high enough that they could introduce it into their diet. But interestingly, the more of the kids that we talk to, it’s uncommon that the kids want to eat the peanuts. You would think all the rest of us who love peanuts, would be the thing they want. But what we find is most of these kids the last thing in the world they want to do is eat it. They just don’t want to think about it. They don’t want to worry about it. These kids, want to be able to go to the party and do everything that everyone else is doing. They don’t have to eat the peanut thing, but not worry that the people around them are eating peanuts or that they took an accidental bite and that something would happen. We do feel good that these treatments can give us that level of protection.
Now, what I had read was that the toothpaste was tested on adults. Has it been tested on children?
Kim: Not yet. We go sequentially. We usually start to prove something safe in adults, and then we slowly go down. The next level of testing would most likely be in adolescents and teenagers, and then go to the youngest kids.
Could you give me the highlights on your study and the results?
Kim: We’ve been excited. We’ve had three generations of sublingual peanut studies here at UNC. The first two generations were in grade school kids about 7 to 8, years old. What we found was even using, again, this 1/150 of a peanut, this tiny, microscopic amount under the tongue, that we could get kids to a point of eating six to 10 peanuts without any symptoms at all. To give a reference on that, typically, if you had a kid that just went out there and took a bite of something by accident, it only takes about one-third of one peanut to cause a reaction. We’re getting way higher than that as far as levels of protection. But in our most recent study, what we wanted to get a sense of is, what if we go even younger? Because it does seem the immune system of young children may be more likely to change and hopefully in a good way. Our most recent study looked at kids between one and four years old, on average about two years old. What we found was an even stronger benefit there. More than half, almost three-fourths of the kids ate the entire serving size of peanuts, so about 15 peanuts without any symptoms at all. What their real threshold is, we don’t know because we didn’t keep pushing them, but at least that amount, they didn’t have any problem. Then what we were excited about was we took the treatment away to get a sense of, whether it this a super temporary thing or are these changes to the immune system were somewhat lasting. Three months later most of those kids, more than half of the kids, again, were still fully protected. It does look like something that can change the immune system and may not be permanent, but at least lasts for some time. That can give some reassurance to families.
Along those lines, what’s the percentage of kids that outgrow their allergy?
Kim: This is one of the reasons we study peanut allergies. Unfortunately, very few. We say about 20 percent of kids, but the reality is, it’s probably a lot lower than that. This is an allergy that is, again, important for us to try to study, to understand, can we make a difference here? Then taking the information we learn from this, and then going to tree nuts and milk and egg and a lot of these other foods to see if we can do the same thing for those allergies as well.
That’s great. What exciting research are you watching about peanuts as well or allergies?
Kim: I think again, the toothpaste, our sublingual, these seem like great ways to handle single allergens like peanut. We think that it would equally work for milk or egg allergy, but we also know that there are a lot of kids out there that unfortunately are allergic to more than one food at the same time. Perhaps they’re allergic to peanut, milk and egg. We could try to do the sublingual, we could try to do the toothpaste, but as you get more and more of those allergies, it gets more complicated to do it. There is a lot of growing research on using some of these biological therapies that would overall dampen your allergic immune system. We’d be excited to see if that can make a difference for food allergies as well and to be able to knock out multiple foods with one treatment would be remarkable.
Would that be something like a patch?
Kim: The patch is another type of treatment that we are interested in as well. Right now, the biologics that I was referring to are more injections, and several of them are already available to treat asthma, allergic rashes, and others. We’re hopeful that those can be brought over to food allergy as well.
Perfect. Anything I’m missing?
Kim: I can add to the patch. You mentioned the patch and I mentioned before how a lot of these kids are not interested in eating the peanut. For a lot of them, the smell, the taste, the texture drives them crazy. But the sublingual, the toothpaste, and then the eating of course all go in the mouth. One thought is, maybe if we can use a medicine patch like you’ve mentioned that’s the way we can access the immune system through the skin but never actually have to go into the mouth. Hopefully, we can avoid what we call the oral aversion and perhaps get some better safety. There have been multiple studies using a commercial peanut patch. We’d be excited to see if that could work because again, I think for my own family, nothing is easier than just putting a sticker on and letting them go about their day. Very excited to see if that can make it to market as well.
END OF INTERVIEW
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