Comparing approaches to ordering peanut component-resolved diagnostics to reduce the need for oral food challenges.

Background: Peanut component-resolved diagnostics (peanut CRD) is a potentially valuable tool for distinguishing between anaphylactic peanut allergies and milder phenotypes, such as pollen-food allergy syndrome. However, the optimal strategy for integrating CRD into clinical practice remains unclear. Objective: This study aims to evaluate the rates of oral food challenge (OFC) when CRD is ordered: routinely for all patients, selectively on the basis of clinical characteristics, or guided by other peanut biomarkers. Methods: We compared OFC rates between 2 cohorts. Cohort 1 included patients with peanut allergy who received CRD as part of routine testing, regardless of clinical features. In cohort 2, CRD was ordered selectively, depending on factors such as older age, comorbidities, or pollen sensitization. OFC was offered at the physician's discretion in both cohorts. Later, a proposed 2-step clinical algorithm was retrospectively applied to the pooled data to determine patients eligible for OFC. Results: A total of 322 patients (137 in cohort 1 and 185 in cohort 2) participated in the study. OFC rates were lower in the selective testing group (9.7%) and with use of an algorithm (9.5%) than in the group that underwent routine testing (25.5%). The correlation between peanut-specific IgE level and CRD result was high ( Conclusion: Offering CRD selectively on the basis of clinical characteristics and being guided by a 2-step algorithm are more efficient strategies that can reduce rates of OFC to enhance patient safety, optimize health care resource utilization, and reduce costs. As peanut-specific IgE level and CRD result correlate well, testing for Ara h 2 is likely redundant at very high and low ranges.