Immune Basis and Clinical Implications of Threshold-based Phenotypes of Peanut Allergy (CAFETERIA)

Challenging to Food With Escalating Thresholds for Reducing Food Allergy

The primary objective of this study is to determine whether allowing ingestion of sub-threshold amounts of peanut in those with a high threshold (tolerate at least 143 mg peanut protein on supervised double-blind, placebo-controlled oral food challenge [DBPCFC]) will be associated with attaining even higher thresholds over time in children with high threshold peanut allergy compared to those avoiding peanut. The secondary clinical objectives include assessing the development of sustained unresponsiveness (SU, a surrogate term for tolerance without daily ingestion), effects on quality of life, and safety compared to those avoiding peanut. Additionally, this study will phenotype the allergic response to peanut based on threshold and response to exposure. Mechanistic study objectives will determine the immune and molecular basis of the high threshold endotype, identify predictors of response to exposure, and determine mechanisms and biomarkers of remission.

Study Overview

• Status: Completed
• Conditions: Peanut Allergy; Food Allergy
• Intervention / Treatment: Biological: Peanut Protein; Other: Continued peanut avoidance

• Study Type: Interventional
• Enrollment (Actual): 73
• Phase: Phase 2

Contacts and Locations

Study Locations

• United States
  • New York
    • New York, New York, United States, 10029
      • Icahn School of Medicine at Mount Sinai

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 4 years to 14 years (Child)
• Accepts Healthy Volunteers: No

Description

Inclusion Criteria:

-Subject and/or parent guardian must be able to understand and provide informed consent.

Inclusion criteria for screening DBPCFC:

• Age 4-14 years
• either sex
• any race, any ethnicity
• who are enrolled while strictly avoiding peanut
• have a history of sensitization (detectable peanut IgE >0.35 kUA/L)

Inclusion criteria for randomization:

• On screening DBPCFC are able to ingest >= 143 mg peanut protein but < 5043 mg peanut protein.
• All children will have documented consent and assent as is appropriate for age.

Exclusion Criteria:

Individuals who meet any of these criteria are not eligible for enrollment as study participants:

• Inability or unwillingness of a participant to give written informed consent or comply with study protocol
• Serum peanut-specific IgE antibody level > 50 kUA/L
• Recent (within the past 2 years) life-threatening (grade 3) anaphylactic reaction to peanut.
• Any disorder in which epinephrine is contraindicated such as known hypertension or cardia rhythm disorders.
• History of chronic disease requiring therapy (other than asthma, atopic dermatitis, rhinitis).
• On a build-up phase of any allergen immunotherapy.

• For those with a history of asthma, the following are assessed and any of the following is an exclusion (markers of current uncontrolled or moderate to severe asthma):

  1. FEV1 value <80% predicted (only for participants age 7 years or older and are able to perform spirometry)
  2. ACT or cACT < 20
  3. >Step 3 controller therapy as defined for children 0-4, 5-11 and >=12 years of age by EPR-3 tables

  4. Use of steroid medications in the following manners:

     1. history of daily oral steroid dosing for >1 month during the past year,
     2. having 1 burst or steroid course within the past 6 months, or
     3. having >1 burst oral steroid course within the past 12 months.
  5. Asthma requiring >1 hospitalization in the past year for asthma or >1 ED visit in the past 6 months for asthma, or any prior intubation/mechanical ventilation for asthma/wheezing.
  6. When COVID related institutional restrictions on spirometry are in effect, spirometry will not be performed and peak flow will be used with 80% predicted as cut-off.
• Gastrointestinal eosinophilic disorders, esophagitis, gastroenteritis.
• Use of short-acting antihistamines (diphenhydramine, etc.) more than one time within 3 days prior to DBPCFC or skin testing.*
• Use of medium-acting antihistamines (hydroxyzine, loratadine, etc.) more than one time within 7 days of DBPCFC or skin testing.*
• Use of systemic steroid medications (IV, IM or oral) for indications other than asthma for > 3 weeks within the past 6 months
• Use of beta-blockers (oral), (ACE) inhibitors, angiotensin-receptor blockers or calcium channel blockers.
• Participation in any trials of therapeutic interventions for food allergy in the past year.
• Therapy with anti-IgE or other biologics, including within 1 year of enrollment.
• Use of investigational drugs within 52 weeks of participation.
• Allergy to all of the following: oat, rice, corn, tapioca.
• Pregnancy
• Past or current medical problems or findings from physical examination or laboratory testing that are not listed above, which, in the opinion of the investigator, may pose additional risks from participation in the study, may interfere with the participant's ability to comply with study requirements or that may impact the quality or interpretation of the data obtained from the study.

*Any subject meeting these criteria during the visits can be rescheduled for the oral food challenge or prick skin testing.*

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Parallel Assignment
• Masking: None (Open Label)

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Active Comparator: Treatment; Ingests peanut - . Depending upon reaction threshold, participants may begin with different starting amounts of store bought peanut butter measured with study-supplied kitchen measuring spoons.	Biological: Peanut Protein; up to 3 level teaspoons peanut butter or equivalent (approximately 3400 mg)
Other: Avoidance; Avoids peanut, standard care	Other: Continued peanut avoidance; Standard of care avoidance of peanut

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Percentage of Children That Tolerate the Full Challenge	The difference between the treatment and comparison (avoidance) groups in the percentage of children who by the endpoint double-blind, placebo-controlled oral food challenge (DBPCFC) tolerate a dose at least 2 steps higher than their baseline DBPCFC or 9043 mg of peanut protein. Due to missing data in the primary endpoint, the protocol & SAP specified a priori that missing data would be imputed using multiple imputation and results based on 30 completed-imputed data sets would be combined using Rubin's rule. In the Peanut Protein group, the observed data was so strong that participants with missing data were also imputed as success across all imputations (hence, 100% success rate). In the Peanut Avoidance group, there was more variability in the proportion of successes across imputations and these varying proportions were averaged. Missing data were imputed and results were pooled.	72 weeks

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
The Percentage of Children That Achieve Sustained Unresponsiveness	The percentage of children who achieve sustained unresponsiveness or natural tolerance during the study.	96 weeks
Number of Children With Acute Allergic Reactions	Safety parameter assessed by number of participants with acute allergic reactions which includes anaphylaxis or gastrointestinal side effects.	96 weeks
Mean Change in Food Allergy Quality of Life Parental Burden Instrument	The Food Allergy Quality of Life-Parental Burden (FAQL-PB) Scale is a 17-item instrument. It utilizes a 7-point Likert scale ranging from 0 (not troubled) to 6 (extremely troubled). The number circled for each question is summed to provide a total continuous score range of 0 to 102 with a higher score indicating greater burden on the family.	baseline and at 72 weeks
Mean Change in SPT Wheal Size	Change in Skin Prick Test (SPT) mean wheal size at 72 weeks as compared to baseline. A skin test reaction is considered positive if the wheal size for the antigen is at least 3 mm larger than the wheal size of the negative control (saline).	Baseline and 72 weeks
Mean Change in Peanut-specific IgE	Mean Change in Peanut-specific IgE level at week 72 as compared to baseline.	Baseline and 72 weeks
Mean Change in Peanut-specific IgG4	Mean Change in Peanut-specific IgG4 level at week 72 as compared to baseline.	Baseline and 72 weeks

Collaborators and Investigators

• Sponsor: Scott Sicherer
• Collaborators: National Institute of Allergy and Infectious Diseases (NIAID)
• Investigators: Principal Investigator: Scott Sicherer, MD, Icahn School of Medicine at Mount Sinai

Study record dates

Study Major Dates

• Study Start (Actual): August 5, 2019
• Primary Completion (Actual): November 17, 2023
• Study Completion (Actual): November 17, 2023

Study Registration Dates

• First Submitted: April 5, 2019
• First Submitted That Met QC Criteria: April 5, 2019
• First Posted (Actual): April 9, 2019

Study Record Updates

• Last Update Posted (Actual): March 25, 2025
• Last Update Submitted That Met QC Criteria: February 5, 2025
• Last Verified: February 1, 2025

More Information

Terms related to this study

• Keywords: immunotherapy; food; allergy; peanut; threshold
• Additional Relevant MeSH Terms: Nut and Peanut Hypersensitivity; Immune System Diseases; Hypersensitivity, Immediate; Hypersensitivity; Food Hypersensitivity; Peanut Hypersensitivity
• Other Study ID Numbers: GCO 17-0722; U19AI136053 (U.S. NIH Grant/Contract)

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: Yes
• Studies a U.S. FDA-regulated device product: No
• product manufactured in and exported from the U.S.: No