The Health and Economic Outcomes of Peanut Allergy Management Practices.

BACKGROUND: Peanut allergy is managed with strict avoidance, epinephrine carriage, and promptly treating reactions.

OBJECTIVE: The objective of this study was to assess the health and economic benefits of pre-emptively injecting epinephrine for peanut ingestion in the absence of any symptoms, and to avoid products with peanut precautionary allergen labeling (PAL).

METHODS: We used Markov modeling and simulations, assuming a base-case 10-fold fatality risk increase for less conservative management, with sensitivity analysis investigating 100- to 1000-fold increased fatality risk, incorporating risks of accidental exposures, reactions, fatality, and family costs of food allergy. Low-dose threshold challenges were used to exclude subjects highly reactive to PAL items.

RESULTS: Based on these assumptions, small reductions in per-patient fatality risk resulted from pre-emptive epinephrine injection without symptoms present (<1 × 10-4 fewer per-patient fatalities), with incremental costs of $1193 per patient, $11,681,501/life year saved, and $110,270,820/death prevented versus waiting for symptoms before use, but this was not cost-effective even assuming 1000-fold risk ($107, 971/quality of life adjusted year) or quality of life (QoL). There were small reductions in per-patient fatality risk (<1 × 10-4 fewer per-patient fatalities) for PAL avoidance versus universal PAL consumption, with incremental costs of $3342 per patient, $19,325,994/life year saved, and $182,434,277/death prevented versus 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 1.5 mg of peanut protein to exclude children reactive to PAL consumption was cost-effective.

CONCLUSIONS: Commonly 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 on symptom development or allowing PAL consumption.