Allergy treatment

Abstract

The present invention relates to a method of treating peanut allergy in a subject or population of subjects, comprising administering a peanut allergen to said subject or population of subjects by an oral immunotherapy (OIT) regimen that includes a dose escalation phase in which the peanut allergen is administered in doses that escalate from an initial dose of the allergen equivalent to 5 mg or less of peanut protein to a dose of the allergen equivalent to 200 mg or more of peanut protein within 4 to 9 weeks of administration of the initial dose, thereby reducing the length of the accumulation phase in the peanut OIT regimen and improving the likelihood or odds of a subject achieving sustained unresponsiveness.

Description

[Technical Field]

[0001] Field The present invention relates to an oral immunotherapy regimen for the treatment of peanut allergy. More specifically, the present invention relates to an oral immunotherapy regimen for the treatment of peanut allergy, comprising the administration of a peanut allergen to a subject, wherein the dose of the peanut allergen is rapidly increased during a dose escalation phase. Even more specifically, the present invention relates to an oral immunotherapy regimen for the treatment of peanut allergy, comprising the administration of a live bacterium and a peanut allergen to a subject, wherein the dose of the peanut allergen is rapidly increased during a dose escalation phase. [Background technology]

[0002] background Several approaches have been explored for the treatment of food allergies. These typically involve a course of immunotherapy, involving periodic, gradual exposure of the subject to increasing doses of the allergen to which they are allergic. Treatment outcomes include desensitization and sustained unresponsiveness (SU). Desensitization is defined as a transient increase in the threshold dose required to elicit an allergic response. This protection can only be maintained if regular exposure to the food allergen continues, for example, with continued treatment. Sustained unresponsiveness is defined as the continued ability to orally ingest a standard supply of food allergen without sustained reaction, eliminating the need for continued regular allergen exposure. This may reflect a state of tolerance, defined as the ability to eat any amount of allergen ad libitum without reaction, eliminating the need for continued regular allergen exposure. In terms of clinical benefit to the patient, assuming treatment is continued indefinitely, desensitization provides protection against accidental exposure to small amounts of allergen, whereas SU provides sustained protection, eliminating the need for continued treatment and thus allowing the patient to incorporate the allergen into their normal diet.

[0003] Sublingual immunotherapy (SLIT) with food allergens has been shown to induce desensitization in a subset of patients with food allergies, but it has limited efficacy and has not been shown to be effective in inducing SU.

[0004] Oral immunotherapy (OIT) with food allergens is effective in inducing desensitization in a high proportion of patients, but has only been shown to induce SU in a small subset of patients (Wood, JACI; vol. 27(3): 151-159, 2017, Vickery et al., JACI; 133(2): 468-75, 2014).

[0005] Typically, food allergen-based OIT (i.e., for the treatment of food allergies) involves the oral administration of regular, increasing doses of food allergen to a food-allergic subject. OIT protocols typically include three phases of treatment: rush, build-up, and maintenance. The rush phase generally begins with a very low dose tolerated by the subject and involves several increasing doses of allergen (e.g., 6-8 doses) administered over the course of a day. The build-up phase generally involves the administration of daily doses of food allergen, typically beginning with the highest tolerated dose during the rush phase (or the cumulative tolerated dose during the rush phase, if all rush-phase doses are tolerated), with dose increases every 1-2 weeks. In the maintenance phase, treatment continues at the highest dose reached during the rush phase, with the same dose of food allergen being provided daily, often for months to years or indefinitely.

[0006] Adverse reactions commonly occur during administration. There is a high risk of severe allergic reactions, particularly during the dose-escalation phase, and especially during the accumulation phase. For this reason, each dose increase during the bolus and accumulation phases is typically performed under in-clinic observation, but reactions may also occur to doses taken at home during the accumulation or maintenance phases.

[0007] Studies of peanut OIT have found that adverse events (AEs) occur more commonly during the accumulation phase, both on dose escalation days and during home administration. Severe reactions, while rare, do occur. The most limited side effect is that 10–20% of subjects experience significant gastrointestinal reactions, leading them to discontinue treatment and fail to complete the accumulation phase. Peanut OIT has also been associated with an increased incidence of eosinophilic esophagitis, an inflammatory bowel condition, necessitating a cessation of OIT treatment. Approaches to minimize the likelihood of AEs have been explored, such as starting the OIT regimen at a very low dose and applying a very gradual dose-escalation schedule during the accumulation phase, or administering the anti-IgE antibody omalizumab (Xolair™) before and during OIT. While this latter approach is effective in reducing the likelihood of AEs, it involves multiple subcutaneous injections of the antibody, making it less attractive to patients. It is also costly. Furthermore, studies administering omalizumab before and during peanut OIT show an increase in peanut-specific IgE levels after discontinuation of omalizumab in subjects receiving omalizumab (see Macginnitie et al., (2017) J Allergy Clin Immunol. 139:873-81). Because increased peanut sIgE levels are indicative of persistent peanut allergy, this suggests that administering omalizumab with OIT does not result in persistent unresponsiveness, despite favoring more rapid dose escalation and desensitization.

[0008] In this study, one of eight subjects treated with sham injections rather than omalizumab before and during peanut OIT tolerated a rapid dose-escalation schedule of peanut OIT (doses of 0.5 mg, 1 mg, 2 mg, 4 mg, 8 mg, 15 mg, 30 mg, 60 mg, 120 mg, and 250 mg of peanut protein every 30 minutes for 1 day) and then pursued a dose-escalation schedule including weekly trial dose increases of 375 mg, 500 mg, 625 mg, 750 mg, 1000 mg, 1250 mg, 1625 mg, and 2000 mg of peanut protein, and while the primary endpoint of tolerating 2000 mg of peanut protein by 20 weeks was met, it is likely that this subject did not actually have a clinical peanut allergy at the time of study enrollment. This is because the criteria for a positive peanut challenge (used to confirm peanut allergy at trial enrollment) were generally reported by allergic patients and did not provide objective evidence of current food allergy; for example, a single placebo patient may simply have experienced several mild (Grade 1) subjective symptoms, such as mild erythema, incidental scratching, incidental sniffing, mild nasal itching, or mild nausea, which would not actually confirm clinical allergy. This would be consistent with the results of other trials of peanut OIT (without adjunctive omalizumab) that reported much longer periods, e.g., 41–44 weeks, for patients to reach a final dose of 800–4000 mg peanut protein (e.g., Anagnostou et al., (2014) Lancet; 383:1297–304). The very low likelihood that placebo subjects in the Macginnitie trial would successfully reach 2000 mg of peanut protein by week 20 reinforces the current standard of care, employing a slow peanut OIT dosing schedule with small dose escalations and discouraging transitions to more rapid dose escalation. It is also possible that these placebo subjects resolved their peanut allergy immediately prior to the trial. Spontaneous resolution of peanut allergy occurs in approximately 20% of lifetime peanut allergy sufferers.Additionally, some subjects may pass the challenge because they have a higher threshold but are still allergic.

[0009] Schneider et al. (2013) J. Allergy Clin Immunol. 132:1368-74 described a further study of omalizumab treatment before and during peanut OIT in patients with high levels of peanut-specific IgE who were at risk for developing significant peanut-induced allergic reactions. The Schneider study showed similar results to previous studies, namely, that omalizumab treatment before and during peanut OIT reduced the number of AEs and allowed subjects to tolerate rapidly increasing doses of peanut, suggesting desensitization. However, increased levels of peanut IgE were found to persist in subjects during maintenance OIT, suggesting that peanut-specific allergic responses were maintained. Immune tolerance to peanut requires non-allergic levels of peanut-specific IgE. Omalizumab treatment before and during peanut OIT allows for a reduction in AEs with rapid dose escalation up to 2000 mg of peanut allergen, but once omalizumab treatment is stopped, extended OIT at a maintenance dose appears to be required to reduce peanut-specific IgE levels.

[0010] Therefore, the standard dose titration or dose escalation protocol for peanut OIT in the absence of prior treatment with omalizumab or similar anti-IgE antibodies provides for gradual dose increases and an extended accumulation phase to minimize adverse reactions. Typically, several incremental doses are administered at 20-30 minute intervals on the first day of treatment (rush day), with dose escalations during the accumulation phase occurring every two weeks. Smaller dose increments and longer durations for each dose (e.g., two weeks or more) during the accumulation phase are considered to reduce the likelihood of adverse reactions. However, because dose escalation is performed in a hospital or specialized center, this can result in an increased number of hospital or physician visits, reduced compliance, increased likelihood of treatment withdrawal (patients failing to complete treatment), and increased costs associated with the delivery of therapeutic agents. Furthermore, long dose titration periods (rush and accumulation phases) that reduce the likelihood of adverse reactions are disruptive and costly for patients and families, potentially increasing the likelihood of withdrawal due to inconvenience.

[0011] The time taken to reach a selected maximum dose will be affected by both the starting and final doses to be achieved. For example, starting from the same dose, the time taken to reach a dose of 200 mg or 300 mg of peanut protein will be shorter than the time taken to reach 800 mg or 2000 mg or more of peanut protein. For example, dose escalation periods have been used in peanut OIT where the time taken to reach a maximum dose ranged from 20 weeks to reach 300 mg of peanut protein to 44 weeks to reach 4000 mg; see, e.g., the PALISADE study conducted by Vickery, N Engl. J Med. (2018) Nov 22;379(21):1991-2001.

[0012] In any typical OIT regimen, if the test finds a response to the dose that is deemed unacceptable, the dose will either be reduced or continued at the same dose for a further period, for example, another 2 weeks, before resuming the prescribed dosing regimen, until the dose is tolerated without reaction.If an adverse reaction occurs on the bolus day, the accumulation phase will begin with the final tolerated dose on the bolus day, and the remaining bolus day dose will be incorporated into the accumulation phase, thereby extending the period until the maintenance dose is reached.Similarly, if a reaction occurs on the dose increase day during the accumulation phase (up to the increased dose), the dose will not be increased, but will be continued at the same dose for a further period, for example, another 2 weeks, before resuming the prescribed dosing regimen.If a reaction occurs at home, the dose will either be reduced or continued for a further period, for example, another 2 weeks, before resuming the prescribed dosing regimen, until the dose is tolerated without reaction.Therefore, the actual period of increasing the dose from the initial OIT dose to the maximum OIT dose in a subject is typically longer than the period described in the proposed OIT schedule.

[0013] Using a low maximum dose (e.g., 800 mg or less) may reduce the accumulation period and minimize inconvenience and cost, but a lower maximum dose is less effective than a higher maximum dose in inducing either desensitization or SU.

[0014] It is well known that rapid dose escalation during the accumulation period in OIT regimen is associated with a high frequency of adverse events.In addition, the number of adverse events can typically delay the period until reaching maintenance dose.As a result, in order to reduce the possibility of adverse events during the accumulation period, it is standard in the field to adopt a slow dose escalation protocol, when the dose is gradually increased over a longer time frame, for example, a time frame of 32 weeks or more, with a slower and more extended accumulation period to minimize adverse reactions. Summary of the Invention [Problem to be solved by the invention]

[0015] It is desired to improve the safety and tolerability of peanut OIT, increase compliance with peanut OIT, and reduce treatment costs while maintaining a high maximum dose and achieving a higher rate of SU along with a higher rate and level of desensitization, thereby providing a safe, tolerable, and effective treatment for peanut allergy. The ability to achieve a high maintenance dose in a reduced time frame without a corresponding increase in adverse events would allow for fewer clinic visits for dose escalation and dramatically improve the feasibility of administering peanut OIT by allowing a high maintenance OIT dose that is effective in achieving desensitization or SU to peanut allergens to be reached within a reduced time frame. Satisfying at least one of these requirements is an objective of preferred embodiments of the present invention. [Means for solving the problem]

[0016] overview Surprisingly, it has now been found that, contrary to current teachings, the accumulation phase of peanut OIT can be reduced compared to existing known peanut OIT protocols that do not include pretreatment with anti-IgE antibodies.It has been found that, without pretreatment with anti-IgE antibodies, it is possible to increase the dose of peanut allergen that should be administered to subjects allergic to peanut allergens more rapidly than previously thought possible, without increasing the incidence of adverse events or dropout rates.Therefore, the present invention provides a treatment plan for peanut allergy that is tolerable and safe in subjects (especially children), and allows maintenance to be reached in a more rapid period, thereby allowing higher doses of peanut allergen to be administered to subjects within a shorter period than currently thought possible without the administration of expensive anti-IgE antibodies.

[0017] Furthermore, this rapid dose escalation has unexpectedly been found to be associated with an increased likelihood of achieving sustained unresponsiveness in subjects after completing treatment.Therefore, this provides an improved oral immunotherapy regimen for treating peanut allergy, comprising the administration of a peanut allergen and optionally live bacteria, wherein treatment includes a dose escalation phase in which the allergen is administered at a dose that is increased from the initial dose more rapidly than would currently be possible without prior treatment with anti-IgE antibody.

[0018] In a first aspect, the present invention provides a method of treating peanut allergy in a subject, comprising administering to the subject a peanut allergen by an oral immunotherapy regimen including a dose escalation phase, wherein the peanut allergen is administered in doses that escalate from an initial dose of the allergen equivalent to 5 mg or less of peanut protein to a dose of the allergen equivalent to 200 mg or more of peanut protein within 4 to 9 weeks of administration of the initial dose, and wherein the peanut allergen is administered orally.

[0019] In a preferred embodiment, the method of the first aspect further comprises orally administering live bacteria at least once weekly during the dose escalation phase of the peanut allergen.

[0020] In a particularly preferred embodiment, the subject is under 10 years old, preferably under 5 years old, especially between 1 and 5 years old.

[0021] In another expression, the present invention provides a peanut allergen for use in treating peanut allergy in a subject, wherein the treatment comprises an oral immunotherapy regimen wherein the peanut allergen is administered in escalating doses from an initial dose of the allergen equivalent to 5 mg or less of peanut protein to a dose of the allergen equivalent to 200 mg or more of peanut protein within 4 to 9 weeks of administration of the initial dose, and including a dose escalation phase wherein the peanut allergen is administered orally.

[0022] A preferred embodiment further comprises live bacteria to be administered orally at least once weekly during the dose escalation phase of the peanut allergen.

[0023] In another expression, the present invention provides the use of a peanut allergen in the manufacture of a medicament for the treatment of peanut allergy in a subject, wherein the medicament is intended for administration in an oral immunotherapy regimen including a dose escalation phase, wherein the peanut allergen is to be administered in doses that are escalated from an initial dose of the allergen equivalent to 5 mg or less of peanut protein to a dose of the allergen equivalent to 200 mg or more of peanut protein within 4 to 9 weeks of administration of the initial dose, and wherein the peanut allergen is to be administered orally.

[0024] In a preferred embodiment, the medicament is for administration to a subject receiving oral administration of live bacteria at least once weekly during the peanut allergen dose escalation phase.

[0025] In a preferred embodiment, the subject has not received anti-IgE antibodies prior to initiation of the OIT regimen or during the dose escalation phase.

[0026] In a preferred embodiment, the method of the first aspect does not include administering an anti-IgE antibody to the subject.

[0027] In a preferred embodiment, the method of the first aspect does not involve injection.

[0028] In a preferred embodiment, in the method of the first aspect, all therapeutic agents are administered parenterally, preferably orally.

[0029] In a preferred embodiment, the only therapeutic agent in the method of the first aspect is a peanut allergen and optionally a live bacteria.

[0030] In one embodiment, the treatment is capable of reducing peanut sIgE levels in a subject from pre-treatment sIgE levels.

[0031] In one embodiment, the peanut sIgE levels in the subject are reduced at the end of the dose-escalation phase compared to pre-treatment sIgE levels.

[0032] In one embodiment, peanut sIgE levels in a subject are reduced at the end of the oral immunotherapy regimen compared to pre-treatment sIgE levels.

[0033] In one embodiment, the peanut sIgE levels in the subject are reduced compared to pre-treatment sIgE levels from 20 weeks onwards after administration of the initial dose.

[0034] In one embodiment, the peanut sIgE levels in the subject are reduced compared to pre-treatment sIgE levels 18 months or more after administration of the initial dose.

[0035] In one embodiment, the reduction in peanut sIgE levels in a subject relative to pre-treatment sIgE levels is up to a 10% reduction, up to a 20% reduction, up to a 30% reduction, up to a 40% reduction, or up to a 50% reduction or more. Preferably, the reduction is at least 20%, more preferably 20-50% or more.

[0036] In a preferred embodiment, the method of treating peanut allergy in a subject comprises administering a peanut allergen alone or a peanut allergen plus live bacteria alone.

[0037] The present invention also provides a live bacteria and a peanut allergen as a combined preparation for simultaneous, separated or sequential use in the treatment of peanut allergy in a subject, wherein the treatment comprises an oral immunotherapy regimen as described herein above.

[0038] The preferred embodiments described herein below in relation to the methods described herein apply equally to the uses described herein.

[0039] Thus, the present invention provides a treatment for peanut allergy that allows for rapid escalation of the dose of peanut allergen administered to a subject from a low initial dose.

[0040] Surprisingly, we found that more rapid dose escalation of OIT without prior or concurrent treatment with an anti-IgE antibody did not result in an increase in adverse events, provided the dose escalation was not too rapid. Furthermore, in contrast to studies using prior or concurrent treatment with an anti-IgE antibody, which resulted in an increase in peanut sIgE levels compared to baseline upon discontinuation of anti-IgE antibody treatment, the rapid dose escalation schedule of the present invention was able to reduce serum peanut-specific IgE levels. This also contrasts with studies of OIT alone, where initial administration of OIT resulted in an increase in blood peanut sIgE levels from baseline (pretreatment levels). These findings suggest that potential peanut-specific allergic immune responses can be modulated by treatment with both OIT alone and OIT with live bacteria according to the dose escalation schedule described herein.

[0041] Furthermore, without wishing to be bound by theory, it is believed that administration of live bacteria allows for the administration of OIT using a more rapid dose escalation regimen with reduced adverse effects during the dose escalation phase of the OIT regimen, thereby improving the tolerability and safety of the more rapid dose escalation regimen of OIT, resulting in fewer study dropouts and fewer responses to treatment.

[0042] The reduced side effects despite the more rapid dose escalation of OIT achieved by the addition of live bacteria are thought to be related to the induction of tolerogenic dendritic cells by the live bacteria, which in turn inhibit the allergic response to peanut allergens (administered in OIT treatment). Side effects that may be reduced include gastrointestinal side effects, including abdominal pain, vomiting, and eosinophilic esophagitis, respiratory symptoms, and systemic allergic reactions, such as anaphylaxis.

[0043] Detailed Description As used herein, the terms "treat," "treated," or "treating" refer to both therapeutic and prophylactic or preventive treatment, the purpose of which is to protect (partially or fully) against or avoid the progression of (e.g., reduce or postpone the onset of) an undesirable physiological condition, disorder, or disease, or to obtain a beneficial or desired clinical result, such as a partial or full reversal or inhibition of a decline in a parameter, value, function, or outcome that has or is thought to be abnormal. For purposes of this application, a beneficial or desired clinical result includes alleviating at least one symptom or reducing the risk, incidence, or severity of an allergic reaction. In certain embodiments, it includes desensitizing a subject, achieving sustained unresponsiveness, or achieving tolerance to a particular allergen, e.g., peanut allergen.

[0044] As used herein, the term "therapeutic agent" refers to agents that provide therapeutic and prophylactic or preventive treatment, the purpose of which is to protect (partially or fully) against or avoid the progression of (e.g., reduce or postpone the onset of) an undesirable physiological condition, disorder, or disease, or to achieve a beneficial or desired clinical result, such as a partial or complete reversal or inhibition of a decline in a parameter, value, function, or outcome that has or is thought to be abnormal. For purposes of this application, a beneficial or desired clinical result includes alleviating at least one symptom or reducing the risk, incidence, or severity of an allergic reaction. In certain embodiments, it includes desensitizing a subject, achieving sustained unresponsiveness, or achieving tolerance to a particular allergen, e.g., peanut allergen.

[0045] "Desensitization" refers to a transient increase in the amount of allergen that a subject may tolerate without the response being lost when immunotherapy or regular allergen exposure is discontinued (i.e., response threshold).

[0046] "Sustained unresponsiveness" or "SU," as used herein, refers to the sustained ability of a subject to tolerate an allergen (e.g., a standard intake or a full diagnostic food challenge to test for the presence of allergy) after cessation of immunotherapy for at least 2-4 weeks, without the need for regular, frequent exposure to the antigen (e.g., as might be necessary if the subject were simply desensitized to the allergen).

[0047] In contrast, "tolerance," as used herein, refers to the long-lasting (e.g., years) or permanent ability of a subject to orally ingest any amount of an allergen via the oral route without a reaction, where continued allergen exposure is not required to maintain such a state. Thus, in certain embodiments, the present invention provides treatments for allergy to peanut allergens that result in sustained unresponsiveness or tolerance, while in other embodiments, may result in desensitization of a subject to the peanut allergen to which they are allergic.

[0048] "Allergy," as used herein, refers to acquired hypersensitivity to an allergen. A subject who has an allergy to an allergen may also be referred to as an allergic subject, and these terms are used interchangeably herein. The present invention relates exclusively to peanut allergy. "Peanut allergy" is an adverse response to one or more peanut allergens, elicited by an immunological reaction to the allergen. Peanut allergy may also be considered an allergy to peanut allergens. Peanut allergy must be distinguished from non-immune-mediated adverse responses to peanuts, such as intolerance and toxin-mediated reactions (e.g., to aflatoxin). Peanut allergy may be IgE-mediated, non-IgE-mediated, or mixed IgE / non-IgE-mediated. In a preferred embodiment, the peanut allergy is IgE-mediated.

[0049] The terms "subject," "individual," or "patient" are used interchangeably and are intended to include human and non-human animals as used herein.

[0050] As used herein, "oral immunotherapy regimen" refers to a treatment plan to be used for the treatment of peanut allergy. This treatment plan involves oral administration of immunotherapy over a long period of time using multiple doses of peanut allergen. Immunotherapy involves the administration of peanut allergen in increasing doses over weeks, months, or years, with the intention of reducing the allergic reaction and stimulating the immune system to achieve desensitization, sustained unresponsiveness, or tolerance. The dose of peanut allergen to be administered is as discussed in more detail below. Additionally, live bacteria may be administered orally during the regimen, as discussed below. As used herein, oral administration refers to administration by mouth, as opposed to sublingual or buccal administration.

[0051] The "dose escalation phase" in an oral immunotherapy regimen refers to the period of the regimen during which the dose of peanut allergen is increased at intervals. The dose escalation phase may include a burst phase and an accumulation phase. The oral immunotherapy regimen may include a maintenance phase following the dose escalation phase. These phases are discussed in more detail below.

[0052] In the method according to the present invention, during the dose escalation phase, the peanut allergen is administered in escalating doses, from an initial dose of 5 mg or less of peanut protein (or allergen equivalent) to 200 mg or more of peanut protein (or allergen equivalent) within 4 to 9 weeks. As referred to herein, the initial dose is any dose of 5 mg or less of peanut protein (or allergen equivalent) during the dose escalation phase. As discussed below, the initial dose is the dose used to calculate the time frame for administering subsequent incremental doses of the allergen during the dose escalation phase. However, this may be the first dose in the dose escalation phase or otherwise. In a preferred embodiment, the initial dose is the first dose of the dose escalation phase and / or the first dose of an oral immunotherapy regimen. However, one or more lower doses of the allergen may be administered to the subject before the initial dose is administered. According to such an embodiment, the time at which the initial dose is administered serves as an appropriate time point for calculating the time frame for administering subsequent incremental doses of the allergen during the dose escalation phase. In other words, the initial dose may be considered as the threshold dose of the allergen, and the time elapsed for administering subsequent higher doses of the allergen during the dose escalation phase may be calculated from the time when this threshold is crossed (i.e., the time when the initial dose is administered).The rapid increase in the dose of peanut allergen to be administered to the subject after the administration of the initial dose of peanut allergen may form a small part of the dose escalation phase (i.e., the total duration of the dose escalation phase may be longer than 9 weeks).Therefore, the dose escalation phase may further include increasing the dose of peanut protein to be administered to a higher level (i.e., higher than 200 mg).

[0053] Thus, in certain embodiments, the dose escalation period may be 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 weeks or less (but more than 4 weeks) if a dose greater than 200 mg is achieved. The dose escalation phase may also include further escalations in the dose of peanut allergen, and in certain embodiments, doses of peanut allergen equivalent to about 300 mg, about 400 mg, about 500 mg, about 600 mg, about 700 mg, about 800 mg, about 900 mg, about 1000 mg, about 1100 mg, about 1200 mg, about 1300 mg, about 1400 mg, about 1500 mg, about 1600 mg, about 1700 mg, about 1800 mg, about 1900 mg, or about 2000 mg or more of peanut protein may be administered (as used herein, "about" refers to a dose that varies by ±10%).

[0054] Thus, according to certain embodiments of the present invention, the dose escalation phase comprises: a) administering a dose of allergen equivalent to 400 mg or more of peanut protein within 11 weeks or less (preferably 10, 9 or 8 weeks or less (but more than 4 weeks), preferably more than 6, 7, 8 or 9 weeks, e.g., 6-11 weeks, 6-10 weeks, 6-9 weeks, 7-11 weeks, 7-10 weeks, 7-9 weeks, 8-11 weeks, 8-10 weeks, 8-9 weeks or 9-11 weeks) of administration of the initial dose; b) administering a dose of allergen equivalent to 800 mg or more of peanut protein within 13 weeks or less (but more than 4 weeks) (preferably 12, 11 or 10 weeks or less (but more than 4 weeks), preferably 8, 9, 10 or more than 11 weeks, e.g., 8-13 weeks, 8-12 weeks, 8-11 weeks, 9-13 weeks, 9-12 weeks, 9-11 weeks, 10-13 weeks, 10-12 weeks, 10-11 weeks or 11-13 weeks) after administration of the initial dose; c) administering a dose of allergen equivalent to 1200 mg or more of peanut protein within 16 weeks or less (but more than 4 weeks) (preferably 15, 14 or 13 weeks or less (but more than 4 weeks), preferably 11, 12, 13 or more than 14 weeks, e.g., 11-16 weeks, 11-15 weeks, 11-14 weeks, 12-16 weeks, 12-15 weeks, 12-14 weeks, 13-16 weeks, 13-15 weeks, 13-14 weeks or 14-16 weeks) after administration of the initial dose; d) administering a dose of an allergen equivalent to 1600 mg or more of peanut protein within 20 weeks or less (but more than 4 weeks) (preferably 19, 18 or 17 weeks or less (but more than 4 weeks), preferably 14, 15, 16, 17 or more than 18 weeks, e.g., 14-20 weeks, 14-19 weeks, 14-18 weeks, 15-20 weeks, 15-19 weeks, 15-18 weeks, 16-20 weeks, 16-19 weeks, 16-18 weeks, 17-20 weeks, 17-19 weeks or 18-20 weeks) after administration of the initial dose; and / or e) A dose of an allergen equivalent to 2000 mg or more of peanut protein is administered 24 weeks or less (but more than 4 weeks) after administration of the initial dose (preferably 23, 22, 21, 20, 19 or 18 weeks or less (but more than 4 weeks), preferably 16, 17 or 18 weeks, 19, 20, 21 or more than 22 weeks, for example 16-24 weeks, 16-23 weeks, 16-22 weeks). , 16-21 weeks, 16-20 weeks, 17-24 weeks, 17-23 weeks, 17-22 weeks, 17-21 weeks, 17-20 weeks, 18-24 weeks, 18-23 weeks, 18-22 weeks, 18-21 weeks, 18-20 weeks, 19-24 weeks, 19-23 weeks, 19-22 weeks, 19-21 weeks, 20-24 weeks, 20-23 weeks, 20-22 weeks, 21-24 weeks, 21-23 weeks, or 22-24 weeks). may include administering a dose of an allergen equivalent to 200 mg or more of peanut protein within 4 to 9 weeks (preferably 8, 7, or 6 weeks or less (but more than 4 weeks), preferably more than 5, 6, or 7 weeks, e.g., 4 to 8 weeks, 4 to 7 weeks, 5 to 9 weeks, 5 to 8 weeks, 5 to 7 weeks, 6 to 9 weeks, 6 to 8 weeks, 6 to 7 weeks, or 7 to 9 weeks) of administering an initial dose of an allergen equivalent to 5 mg or less of peanut protein, in combination with one or more of (in any combination). As listed above, a) to e) are typically not performed separately, but may be performed cumulatively, e.g., any or all of a) to d) may be performed while e) is being performed.

[0055] In alternative embodiments, any combination of a)-e) may be performed independently (as described above) of achieving a dose of allergen equivalent to 200 mg or more of peanut protein within 4-9 weeks of administration of the initial dose; i.e., this initial dose escalation to 200 mg is not necessarily achieved within 4-9 weeks of administration of the initial dose. Thus, for example, if treatment a) is to be used, its use in treating peanut allergy may include an oral immunotherapy regimen in which peanut allergen is administered at doses that escalate from an initial dose of 5 mg or less of allergen equivalent to peanut protein to a dose of allergen equivalent to 400 mg or more of peanut protein within 11 weeks (e.g., 6-11 weeks) or less (but more than 4 weeks) of administration of the initial dose, and the peanut allergen is administered orally, and further, this may not necessarily include reaching a dose of 200 mg within 4-9 weeks. Similar considerations apply to treatments b)-e), which may be used alone or in combination. The preferred aspects for these embodiments as described herein apply to these aspects of the invention as well.

[0056] In certain exemplary embodiments, the peanut allergen dose may be titrated up to a dose of allergen equivalent to 800 mg or more of peanut protein within 13 weeks or less (but more than 4 weeks) (preferably 12, 11, or 10 weeks or less, or as described above, preferably 8-13 weeks) from administration of the initial dose. In further exemplary embodiments, the peanut allergen dose may additionally or alternatively be titrated up to a dose of allergen equivalent to 2000 mg or more of peanut protein within 24 weeks or less (but more than 4 weeks) (preferably 23, 22, 21, 20, 19, or 18 weeks or less (but more than 4 weeks), or as described above, preferably 16-24 weeks) from administration of the initial dose.

[0057] In certain embodiments, the dose escalation phase comprises: a) A dose of allergen equivalent to 400 mg or more of peanut protein administered within 7 to 11 weeks of the initial dose; b) A dose of allergen equivalent to 800 mg or more of peanut protein is administered within 9 to 13 weeks of the initial dose; c) A dose of allergen equivalent to 1200 mg or more of peanut protein is administered within 11 to 16 weeks of the initial dose; d) A dose of an allergen equivalent to 1600 mg or more of peanut protein is administered within 14 to 20 weeks of the initial dose; and / or e) A dose of allergen equivalent to 2000 mg or more of peanut protein should be administered within 16 to 24 weeks, preferably 16 to 20 weeks, after administration of the initial dose. (in any combination), within 6 to 9 weeks (e.g., within 7, 8, or 9 weeks) of administering an initial dose of allergen equivalent to 5 mg or less of peanut protein.

[0058] As previously mentioned in alternative embodiments of the present invention, these treatment steps may be performed independently of the initial steps.

[0059] According to certain exemplary embodiments, between administration of an initial dose of 5 mg or less of peanut protein and administration of a dose of 200 mg or more of peanut protein, the dose escalation phase may include administering a dose of allergen equivalent to 25 mg or more of peanut protein within 2 weeks or less (preferably 1 week or less) of administration of the initial dose, a dose of allergen equivalent to 50 mg or more of peanut protein within 5 weeks or less (preferably 2 weeks or less) of administration of the initial dose, and / or a dose of allergen equivalent to 100 mg or more of peanut protein within 7 weeks or less (preferably 5 or 4 weeks) of administration of the initial dose.

[0060] The term "dose" as used herein refers to a dose or a dosage administration. For example, a 5 mg dose may be administered on multiple occasions, i.e., multiple administrations. Whether "dose" refers to an amount or an administered dose is clear from the context in which it is used.

[0061] The initial dose of allergen to be administered to a subject is an allergen equivalent to 5 mg or less of peanut protein. Thus, in certain embodiments, the initial dose to be administered to a subject may be an allergen equivalent to about 4 mg, about 3 mg, about 2 mg, about 1 mg, or less of peanut protein, e.g., about 0.9 mg, about 0.8 mg, about 0.7 mg, about 0.6 mg, about 0.5 mg, about 0.4 mg, about 0.3 mg, about 0.2 mg, or about 0.1 mg, or less of peanut protein. In certain exemplary embodiments, the initial dose may be an allergen equivalent to 2 mg or less of peanut protein. Preferably, the initial dose is at least 0.1 mg, 0.5 mg, or 1 mg of peanut protein (or allergen equivalent). In preferred embodiments, the initial dose is 0.1 to 5 mg, 0.1 to 3 mg, or 0.5 to 5 mg of peanut protein (or allergen equivalent), or any other range combining the upper and lower limits of the doses listed above. Without wishing to be bound by theory, it is believed that a low initial dose of allergen may be tolerated by most subjects with peanut allergies, allowing for a rapid increase in the dose of allergen administered to the subject during the dose escalation phase.

[0062] During the dose escalation phase, the dose of allergen administered to a subject is gradually increased from the initial dose. As referred to herein, "escalation" refers to an increase in dose during the dose escalation phase. Preferably, these increases are regular in nature, e.g., doubling over a specific time period (e.g., every 10-18 days, e.g., every 2 weeks). However, rapid (incremental) increase periods (e.g., the rapid phase discussed below) are also contemplated. In a preferred embodiment, the subject may receive the same dose for a period of time before the dose is increased, i.e., achieving a stepwise increase in dose, with multiple doses at a common dose being administered before the increase. This is common in oral immunotherapy regimens. When multiple doses at a common dose (e.g., 200 mg) are used, the first dose of that dose is used to calculate the time it takes to ramp from the initial dose to that dose. (This applies to both the initial dose and subsequent doses; i.e., the first dose of the appropriate dose is used to calculate the appropriate time period.)

[0063] Dose escalation allows for the dose to be gradually increased over time, thereby minimizing the risk of the subject suffering from adverse reactions to the allergen. Without wishing to be bound by theory, it is believed that when allergic subjects are exposed to increasing doses of peanut allergen, they can develop tolerance to the increasing doses of the allergen. Therefore, an increase in the tolerable dose of the allergen is less likely to cause adverse reactions during the dose escalation period. Therefore, the dose is increased multiple times or in multiple increments during the dose escalation period in a particular dosing regimen. As described above, the dose may typically be increased after a period of administration at the same dose (e.g., 2 weeks). Thus, according to certain embodiments, the dose may be increased every 2 weeks or more after multiple administrations at the same dose (e.g., 5 or more administrations at the same dose).

[0064] The factors when the dose of allergen to be administered to a subject is increased between successive administrations (doses or successive increments) may depend on factors such as the frequency of administration of the allergen and how often the dose should be increased.

[0065] Thus, in certain embodiments, the dose escalation phase may include a series of increases in dose from the initial dose of 5%, 10%, 15%, 20%, 25%, 30%, 40%, 50%, 60%, 70%, 80%, 90%, or 100% (or more, e.g., 5% or more, for each preceding percentage) for each increase. As noted above, the dose may be held at the same level for several doses before being increased as described herein.

[0066] In certain exemplary embodiments, the dose escalation phase may include a series of approximately doubling dose increments from the initial dose to the higher doses recited herein, and in particularly preferred embodiments, may include a series of approximately doubling dose increments from the initial dose of peanut protein to doses (or allergen equivalents) of 200 mg, 400 mg, 800 mg, 1000 mg, and / or 2000 mg or more, particularly within the specified preferred time frames outlined above. As referred to herein, "roughly" refers to a lack of mathematical precision in measuring or timing the dose, including 10% or 20% variation in measuring or timing the dose. Synonyms for roughly include, but are not limited to, approximately, about, or around, which have the same definition as roughly when used herein. Higher doses, eg, doses above 800 mg, may be increased at more gradual rates, eg, about 25-50% per increase compared to the previous dose.

[0067] The dose (amount) of allergen may be increased at least monthly, i.e., the dose may be increased every 4 weeks (e.g., 24-32 days), every 3 weeks (e.g., 17-24 days), every 2 weeks (biweekly) (e.g., 10-18 days), or every week (e.g., 3-11 days). Alternatively, the dose may be increased more frequently, e.g., every 6 days, 5 days, 4 days, 3 days, 2 days, or daily. In other embodiments, the allergen dose may be increased multiple times within a day, i.e., the subject may receive multiple increased doses of allergen within a single day. Thus, the allergen dose may be increased every 12 hours, 6 hours, 4 hours, 3 hours, 2 hours, 1 hour, 45 minutes, 30 minutes, 20 minutes, 15 minutes, or 10 minutes. The dose of allergen may be increased at any convenient interval, and optionally the time elapsed between successive increases in the dose of allergen may be varied at different times during the dose escalation phase. Thus, by way of representative example, the dose escalation phase may include a series of dose increases, such as increasing the dose of allergen every 30 minutes for up to 12 hours, followed by increasing the dose of allergen every two weeks (e.g., 10-18 days).

[0068] In a preferred embodiment, the escalation of the allergen dose may be stepwise, i.e., the dose escalation phase may include at least a period in which a specific dose of the allergen is administered to the subject periodically and / or repeatedly over a period of time, followed by a period in which a higher specific dose of the allergen is administered to the subject periodically and / or repeatedly over a period of time. In a particularly preferred embodiment, the dose escalation phase may include at least a period in which a specific dose of the allergen may be administered to the subject periodically (preferably daily) for at least one week, for example up to two weeks (including the same day), (e.g., four weeks (e.g., 24-32 days), three weeks (e.g., 17-24 days), two weeks (biweekly) (e.g., 10-18 days), or one week (e.g., 3-11 days)), followed by an increase in the dose of the allergen. Thus, the allergen dose may be increased every one to two weeks, e.g., every two weeks.

[0069] Alternatively, each dose of allergen to be administered to the subject may be a higher dose than the previous dose. Thus, according to such embodiments, more divided doses (amounts) of allergen may be administered to the subject, although preferably such embodiments may involve increasing each dose (amount) by smaller increments than the stepwise embodiments referenced above. However, the net effect of gradually increasing the dose of allergen to be administered to the subject is that a particular higher dose of allergen may be reached within a particular period of time, as listed herein.

[0070] In a preferred aspect, the dosages and timing are generally as set forth in Examples 1 and 3 provided herein.

[0071] According to certain embodiments, the dose escalation phase may include a rapid phase. The "rapid phase" of a dosing regimen refers to a period when the dose of an allergen is rapidly increased in short intervals over a short period of time from an initial dose, particularly in a clinical setting such as a hospital or under clinical supervision when the subject would experience adverse effects from administration of the allergen. According to preferred embodiments, the rapid phase is the start of the dose escalation phase and may optionally include the initial administration.

[0072] According to particularly preferred embodiments of the present invention, the rapid phase may be completed within 1-7 days (e.g., at the timings discussed above), and the subject may be administered doses of allergen equivalent to about 0.1 mg, about 0.2 mg, about 0.4 mg, about 0.8 mg, about 1.5 mg, about 3 mg, about 6 mg, and about 12 mg of peanut protein, preferably every 15-30 minutes until a dose of 12 mg is reached. Preferably, such doses may be administered following a single dose of live bacteria.

[0073] Thus, in one particular exemplary embodiment, the dose escalation phase may include a rapid phase in which peanut allergen is administered in doses that are escalated from an initial dose to a dose of allergen equivalent to 12 mg or more of peanut protein within one week or less (e.g., one hour to one week) of administration of the initial dose.

[0074] In preferred embodiments, the rapid phase may be completed within 12 hours or less (eg, 1 to 12 hours).

[0075] In a preferred embodiment, the maximum dose of peanut allergen administered during the acute phase is 100 mg or less, more preferably 50 mg or less or 25 mg or less. In a particular daily acute phase, the maximum dose of peanut allergen administered is 24 mg.

[0076] The burst phase may comprise the administration of at least one dose of live bacteria. A burst phase of one week or less may comprise the administration of a single dose of live bacteria or two or more doses of live bacteria. In a burst phase longer than one day (e.g., a burst phase of two or more days), it may be preferred that two or more doses of live bacteria are administered, e.g., a dose of live bacteria is administered on each day of the burst phase. Preferably, the burst phase may comprise the administration of live bacteria on the first day only, i.e., in certain embodiments, the live bacteria will be administered on the first day (only) of the burst phase. Furthermore, preferably, the live bacteria may be administered before the administration of the allergen during the burst phase, or may be administered before the administration of the allergen on the day of the burst phase. After completion of the burst phase, the live bacteria may be administered on at least a weekly basis during the remainder of the dose escalation and / or maintenance phase, as described below.

[0077] Thus, in a preferred embodiment, live bacteria are administered at least once during the acceleration phase and at least once weekly thereafter. Administration of live bacteria during the remainder of the dose escalation phase is further discussed below.

[0078] During the dose escalation phase, the timing for administration of the dose (dosage and amount) is selected (based on the timing described above) taking into account the subject's response to peanut allergen administration before any dose increase is implemented. Thus, the oral dose (amount) of peanut allergen (e.g., via daily administration) may be increased according to the timing described above (e.g., after 2 weeks or less) if, in the week prior to the proposed increase, the patient has not suffered from repeated adverse allergic reactions, has not required anti-allergy treatment, has not suffered from concurrent illnesses or been vaccinated, or has not experienced other cofactors known to increase the likelihood of adverse reactions to OIT, such as asthma or hay fever, acute exacerbation of menstruation, or has not exercised within 2-4 hours of administration of OIT.

[0079] An adverse allergic reaction may include an acute exacerbation of allergic signs or symptoms.

[0080] If an individual has suffered an adverse allergic reaction, is receiving anti-allergy treatment, or has a concurrent illness in the week prior to a proposed dose escalation, the same dose (without the escalation) may be maintained (e.g., for an additional 2 weeks) before further dose escalation.

[0081] Individuals may be monitored for adverse reactions for two hours after administration of each incremental dose of allergen. For example, patients may be evaluated before administration and parameters such as pulse, blood pressure, peak expiratory flow rate within 1 second, and oxygen saturation may be measured. Incremental doses are then administered, and the patient is monitored for the onset of allergic symptoms and / or changes in any of the measured parameters. Allergic symptoms may be treated with conventional medications as needed.

[0082] If an individual experiences a severe adverse reaction to administration of an escalating dose of peanut allergen, such as wheezing or other allergic symptoms assessed as severe by a clinician (such as severe recurring abdominal pain lasting more than 20 minutes, wheezing, throat tightness, hypotension, collapse and nausea / vomiting, or recurring urticaria and angioedema), the dose (e.g., daily dose) may be reduced to the previous dose used before escalation. After a further period (e.g., 2 weeks) at the previous dose, the dose may then be increased again to the next escalating dose.

[0083] In the dose escalation phase as used herein, the dose of allergen administered to the subject is increased over time. The point at which the dose of allergen administered to the subject no longer increases indicates the end of the dose escalation phase. Therefore, the dose (amount) reached at the end of the dose escalation phase may be considered the "final" dose (amount) of the allergen during the dose escalation phase (not necessarily equal to the final dose (amount) of the OIT regimen), and the length of the dose escalation phase is the period from the administration of the initial dose to the arrival of the final dose (amount). Generally, this final dose is equal to the maximum dose reached during the dose escalation phase. When determining the timing of the end of the dose escalation phase, if multiple doses are administered at the same dose, the final dose corresponds to the first dose administration of the final dose (amount) in the dose escalation phase. Furthermore, the dose (amount or administered) of peanut allergen may be administered to the subject (e.g., during the maintenance phase as described elsewhere herein).

[0084] In certain embodiments, the dose escalation period may be 24 weeks or less, e.g., 22 weeks or less, 20 weeks or less, 18 weeks or less, 16 weeks or less, 14 weeks or less, 12 weeks or less, or 10 weeks or less. Preferably, the dose escalation period is at least 8 weeks, 10 weeks, 12 weeks, 14 weeks, 16 weeks, 18 weeks, or 20 weeks. Preferably, the dose escalation period is 8 to 24 weeks. However, it is not excluded that the total length of the dose escalation period may be longer, e.g., than 24 weeks, provided that the dose escalation period increases as recited in the treatments of the present invention (i.e., such embodiments may include an initial rapid increase in the dose of allergen, followed by a more gradual increase). Thus, longer dose escalation periods of 24 weeks or more, e.g., 26 weeks or more, 28 weeks or more, 30 weeks or more, 32 weeks or more, 36 weeks or more, 40 weeks or more, 44 weeks or more, 48 weeks or more, or 52 weeks or more, are encompassed by the present invention. Similarly, treatments that include a dose-escalation phase followed by an extended period of administration of a specific dose (amount) of allergen, followed by another dose-escalation phase, are also encompassed. It should be understood that the dose-escalation phase also includes a 1-day burst phase before the start of the accumulation phase. For example, an accumulation phase of about 9 weeks means 9 weeks and 1 day. Similarly, an accumulation phase of about 16 weeks means 16 weeks and 1 day.

[0085] The final dose (amount) of peanut protein in OIT regimen may depend to some extent on the duration of the dose escalation period, since a longer dose escalation period typically allows a higher dose of peanut protein to be reached.In certain embodiments, the final dose (amount) is equal to the dose that is likely to be encountered in a normal non-elimination diet, so that it can be safely ingested without suffering from adverse events.In other embodiments, the final dose may be equal to the dose that protects against accidental exposure to small amounts of peanut protein remaining in an allergen-elimination diet.

[0086] Depending on the rate of dose escalation, shorter dose escalation periods may be associated with lower final doses than longer dose escalation periods. Thus, by way of example, if the dose escalation period according to the invention is 4-9 weeks (e.g., 5-9 weeks), a final dose of allergen equivalent to 200 mg or more of peanut protein may be reached, while if the dose escalation period according to the invention is 24 weeks or less (e.g., 16-24 weeks), a final dose of allergen equivalent to 2000 mg or more of peanut protein may be reached.

[0087] In certain exemplary embodiments, after the dose escalation phase is completed, the treatment of the present invention may include a maintenance phase. As used herein, the term "maintenance phase" refers to the period when the dose of immunotherapy (in this case, peanut allergen) is maintained until the immunotherapy is discontinued. The maintenance phase is characterized in that the amount of allergen to be administered is the set dose, i.e., the maintenance dose. In certain exemplary embodiments, the maintenance dose is approximately (e.g., + / - 10%) the final dose (amount) reached at the end of the dose escalation phase. Therefore, the final dose, and thus the length of the dose escalation phase, may affect the maintenance dose of allergen to be administered in the maintenance phase after the completion of the dose escalation phase. In certain embodiments, if a subject experiences a serious adverse reaction during the maintenance phase, the final dose (amount) or maintenance dose may be reduced to the most recent dose in the accumulation phase for a certain period of time, e.g., about 2 weeks, and if no further serious adverse reactions occur, the maintenance dose is reset to its original dose (amount).

[0088] The maintenance dose may be any dose that is effective for treating peanut allergy or allergy to peanut allergens. Preferably, according to the present invention, the maintenance dose is an allergen equivalent to at least 200 mg, preferably at least 400 mg or 800 mg of peanut protein, or particularly preferably at least 2000 mg of peanut protein. The maintenance dose may be about 200 mg, about 300 mg, about 400 mg, about 500 mg, about 600 mg, about 700 mg, about 800 mg, about 900 mg, about 1000 mg, about 1100 mg, about 1200 mg, about 1300 mg, about 1400 mg, about 1500 mg, about 1600 mg, about 1700 mg, about 1800 mg, about 1900 mg, about 2000 mg, about 2100 mg, about 2200 mg, about 2300 mg, about 2400 mg, about 2500 mg, about 2600 mg, about 2700 mg, about 2800 mg, about 2900 mg, about 3000 mg, about 3100 mg, about 3200 mg, about 3300 mg, about 3400 mg, about 3500 mg, about 3600 mg, about 3700 mg, about 3800 mg, about 3900 mg, about 4000 mg, about 4100 mg, about 4200 mg, about 4300 mg, about 4400 mg, about 4500 mg, about 4600 mg, about 4700 mg, about 4800 mg, about 4900 mg, about 500 mg, about 5100 mg, about 5200 mg, about 5300 mg, about 540 The maintenance dose may be selected from an allergen equivalent to about 2500 mg, about 2600 mg, about 2700 mg, about 2800 mg, about 2900 mg, about 3000 mg, about 3100 mg, about 3200 mg, about 3300 mg, about 3400 mg, about 3500 mg, about 3600 mg, about 3700 mg, about 3800 mg, about 3900 mg, about 4000 mg, about 4100 mg, or about 4200 mg of peanut protein. A preferred maintenance dose is 200 mg to 4000 mg, preferably 800 mg to 2000 mg of peanut protein (or allergen equivalent).

[0089] The duration of the maintenance phase may be determined by factors such as the outcome intended to be achieved by OIT. For example, whether the intended outcome is sustained unresponsiveness or oral tolerance, which allows subjects to discontinue OIT and assume free ingestion of the allergen in their diet; or desensitization, which requires continued regular exposure to the allergen to maintain protection against accidental ingestion of limited amounts of the allergen. Studies suggest that longer overall OIT durations increase the likelihood of achieving sustained unresponsiveness. Shorter OIT durations typically induce desensitization, but only a small subset of treated subjects achieve sustained unresponsiveness or tolerance. Desensitized subjects must continue regular peanut allergen exposure, e.g., continued OIT treatment or regular peanut allergen ingestion, to maintain the achieved level of protection indefinitely.

[0090] Typically, in oral immunotherapy regimens in the art, the duration of the maintenance phase is at least 12 months or longer, e.g., 18, 24, 36, 48, or 60 months, as a longer maintenance phase may increase the likelihood of achieving sustained unresponsiveness, and such durations may be used in accordance with the present invention. According to certain embodiments of the present invention, the duration of the maintenance phase may be at least 12, 24, 36, 48, or 60 months (up to 5 years) after completion of the dose-escalation phase.

[0091] However, in certain embodiments, a shorter maintenance phase, for example, less than 12 months, may also be used, and it may be advantageous to shorten the duration of the maintenance phase in conjunction with the shortening of the dose-escalation phase, which is the subject of the present invention, in order to dramatically reduce the overall duration of treatment. Thus, according to certain embodiments, the duration of the maintenance phase may be 24 months or 12 months or less, for example, 48 weeks, 44 weeks, 40 weeks, 36 weeks, 32 weeks, 30 weeks, 28 weeks, 26 weeks, 24 weeks, 22 weeks, or 20 weeks or less, preferably at least 10 weeks, 15 weeks, or 20 weeks, after the completion of the dose-escalation phase. In a further aspect, the maintenance phase may be 18 weeks, 16 weeks, 14 weeks, 12 weeks, 10 weeks, 8 weeks, 6 weeks, or 4 weeks or less.

[0092] Preferably, the maintenance phase is at least 2 weeks in duration, e.g., 3, 4, 6, 8, 10, 12, 14, 16, 18, 20, 22, 24, 26, 28, 30, 32, 34, 36, 38, 40, 42, 44, 46, 48, 50, or 52 weeks or more in duration. In alternative preferred embodiments, the maintenance phase may be 56, 60, 64, 68, 72, 76, 80, 84, 88, 92, 96, 100, or 104 weeks or more in duration.

[0093] The upper and lower limits of the range of the duration of the maintenance phase may be obtained from the values ​​described herein. In particular, the duration of the maintenance phase may be preferably 2 to 104 weeks, for example, 20 to 104 weeks, more preferably 40 to 80 weeks, and most preferably 52 to 68 weeks.

[0094] In some embodiments, the maintenance phase is administered for a period of about 5 months to about 5 years. In some embodiments, the maintenance phase comprises orally administering to a subject in need thereof, once daily, about 200 mg to about 4200 mg of peanut protein or its allergen equivalent, and optionally live bacteria, wherein the daily dose of peanut protein is equal to the final dose achieved during the accumulation phase and is maintained throughout the entire maintenance period. In some embodiments, if the subject experiences an adverse reaction to peanut protein, the maintenance dose is reduced to a previous lower escalation dose over a period of time and then increased back to the original maintenance dose. In some embodiments, the maintenance phase follows an accumulation phase following a rapid phase.

[0095] In a preferred embodiment, the treatment of the present invention may include a dose-escalation phase, including a ramp-up phase and a maintenance phase, in which the dose of peanut allergen is increased to at least 2000 mg within 24 weeks or less (e.g., 16-24 weeks), preferably 20 weeks or less (e.g., 16-20 weeks) from administration of the initial dose, the maintenance dose is about 2000 mg or more, and the maintenance phase lasts 62 weeks or less (e.g., 10-40 weeks). Preferably, according to such an embodiment, the dose of peanut allergen may be increased from an allergen equivalent to 0.1 mg of peanut protein to an allergen equivalent to 12 mg of peanut protein in a ramp-up phase consisting of one day or less. In a further embodiment, the dose of peanut allergen may be increased approximately every two weeks after completion of the ramp-up phase until the maintenance dose is reached.

[0096] The level of anti-peanut IgE in a patient's serum or as measured by skin prick testing may be assessed before, during, or after the oral immunotherapy regimen described herein. The level of anti-peanut IgE in a patient before treatment may predict the amount of desensitization that may occur. For example, a low level of anti-peanut IgE may indicate that the treatment is well tolerated and effective in an individual; for example, a change to a lower dose (preferably no change) may be made due to a reaction to OIT, and the patient is more likely to tolerate larger amounts of peanut at the end of OIT if challenged after treatment. In some embodiments, the number of escalating doses required to reach the maximum dose of peanut protein may be reduced in individuals with low initial levels of anti-peanut IgE. Thus, the level of anti-peanut IgE in a patient's serum or by skin prick testing may be measured prior to the dose escalation phase, e.g., before the start of the rapid phase.

[0097] IgE levels may also be measured before, during or after the dose escalation phase and / or before, during or after the maintenance phase of treatment.

[0098] The level of anti-peanut IgE in the blood is a surrogate marker for clinical peanut reactivity and may be an indicator of the effectiveness of treatment. Typically, anti-peanut IgE levels increase initially during OIT treatment and then gradually decrease to lower levels. After treatment, the level of anti-peanut IgE in the blood may increase from pretreatment levels, remain unchanged (associated with desensitization), decrease from pretreatment levels (associated with persistent unresponsiveness), or disappear (associated with tolerance).

[0099] Administration of the maintenance dose during the maintenance phase may be continued until the patient's serum or plasma anti-peanut IgE levels are minimized and the patient no longer reacts to peanut proteins. For example, the anti-peanut IgE levels may be reduced to zero, substantially zero, or very low levels. Advantageously, a serum level of less than 0.35 kU / L is achieved.

[0100] Thus, in a preferred embodiment, the level of IgE reactive to a particular allergen, e.g., Ara h2, is measured in the patient's serum or via skin prick testing, e.g., before, during, or after treatment as described herein.

[0101] In the methods of the invention, a patient's sensitivity to peanut proteins may be reduced or eliminated after treatment. For example, the maximum oral dose of peanut allergen tolerated by a patient without the development of allergic symptoms, or the median maximum oral dose of peanut allergen tolerated by a population of patients, may be increased by at least 3-fold, 5-fold, 10-fold, 20-fold, 50-fold, at least 500-fold, at least 750-fold, or at least 1000-fold after treatment compared to before treatment.

[0102] Oral immunotherapy regimens require regular administration of an allergen to a subject allergic to it in order for the cumulative effect of the treatment to be felt. Therefore, according to the treatment of the present invention, a peanut allergen is administered to a subject regularly during the dose escalation phase and any maintenance phase. Therefore, preferably, a peanut allergen dose is administered to a subject at least every three days, or more preferably at least every two days, during the dose escalation phase and / or maintenance phase. In a further preferred embodiment, a peanut allergen is administered to a subject daily during the dose escalation phase and / or maintenance phase, i.e., a daily dose is provided. As used herein, a "daily" dose refers to a dose administered every 18 to 30 hours, optionally every 22 to 26 hours, and optionally every 24 hours. Patient compliance is greater when doses are administered simultaneously every day, for example, upon waking, at lunchtime, or before bedtime.

[0103] Regardless of the frequency of administration of the allergen, in some embodiments, live bacteria are also administered to the subject periodically in the treatment of the present invention. The live bacteria are also administered orally. Without wishing to be bound by theory, it is believed that the live bacteria may colonize the subject's intestine after administration, interact with components of the subject's immune system, and / or reduce small intestinal inflammation. Regular administration of the live bacteria is required to ensure that the effects are not transient during treatment, i.e., to ensure that the beneficial effects of the live bacteria are felt by the subject during the course of the treatment of the present invention. Accordingly, the treatment of the present invention may require that the live bacteria be administered to the subject at least weekly (i.e., at least once a week) during the dose escalation phase. Advantageously, the live bacteria may also be administered to the subject at least weekly during any maintenance phase. In certain embodiments, the live bacteria may be administered to the subject at least once every three days during the dose escalation phase and / or maintenance phase, more preferably at least every two days or every day.

[0104] When administered, it is preferred that live bacteria be administered at a dose sufficient to allow sufficient live cells to safely pass through the subject's stomach so that their beneficial effects can be felt by the subject. Live bacteria are a novel dietary supplement, and the dose of live bacteria administered to allow the live bacteria to reach the intestine in numbers suitable to provide a health benefit to the subject is known and can vary between live bacteria. A suitable dose is 1 x 10 6 , 5×10 6 , 1×10 7 , 5×10 7 or 1 x 10 8 Any one of CFU to 5 × 10 8 , 1×10 9 , 5×10 9 , 1×10 10 , 2 × 10 10 , 5×10 10 , 1×10 11 or 1 x 10 12 Any one of the CFU, e.g., 1 x 10 6 ~1×10 12 , 5×10 6 ~1×10 11 , 1×10 7 ~5×10 10 , 1×10 8 ~2×10 10 , 1×10 6 ~1×10 8 , 1×10 7 ~1×10 9 , 1×10 8 ~1×10 10 , 1×10 9 ~1×10 11 or 1 x 10 10 ~1×10 12 However, typically 1 × 10 8 CFU ~ 2 × 10 10The dosage of live bacteria within the range of CFU is recommended, and this dosage of live bacteria can be preferably administered in the treatment of the present invention.Therefore, the dosage within this range can be administered to the subject according to the treatment of the present invention at least every week, or at least every 3 days, every 2 days, or preferably every day.In one embodiment, the same dosage of live bacteria is used in each administration.But in other embodiments, dosage can optionally be varied, for example, the dosage of live bacteria can increase during the course of treatment, for example, according to the increase in the dosage of peanut allergen.

[0105] As used herein, "live bacteria" refers to microorganisms that confer a health benefit to the host. In a preferred embodiment, the live bacteria to be used are capable of inducing an increase in the number of tolerogenic dendritic cells, such as pDCs, CD103+ DCs, or other tolerogenic DCs, after in vivo administration. In particular, live bacteria capable of inducing an increase in the number of pDCs may be used. Such an increase in number may essentially result from enhanced proliferation, differentiation, or mobilization of progenitor cells or tolerogenic DCs (such as pDCs) into the circulation or intestine. Preferably, the increase results from proliferation or differentiation.

[0106] Food allergies result from the inability to develop tolerance to food antigens. Tolerance is an active immune response to a food antigen that results in the medium- or long-term ability of the immune system to not develop an adverse reaction to that allergen. While the exact mechanisms that lead to the development of allergy over tolerance are not fully understood, factors such as the local immune environment at the site of initial encounter with the food antigen may play a role, determining whether tolerance is achieved or allergy develops. Dendritic cells are thought to play a central role in determining whether tolerance is achieved or allergy develops. Dendritic cells function by processing antigens and presenting them to naive T cells with specificity for the antigen, guiding the differentiation of antigen-specific naive T cells along selective pathways of response. Without wishing to be bound by theory, it is believed that the subtype of dendritic cells that present antigens to T cells determines the direction of T cell differentiation. For example, activated DCs can induce the differentiation of naive T cells into Th2 cells, which then lead to the development of IgE antibody-producing B cells, mast cells, and eosinophils (i.e., the trio of cells involved in allergic inflammation), while tolerogenic DCs, such as plasmacytoid DCs (pDCs), induce the differentiation of naive T cells into T regulatory cells (Tregs), resulting in a tolerance response.

[0107] Both non-allergic and allergic subjects have detectable populations of both allergen-specific Th2 cells (which drive the allergic response) and allergen-specific Treg cells (which support tolerance); and the overall balance of allergen-specific Th2:allergen-specific Treg cells in an individual is thought to determine that individual's subsequent tolerance to the clinical phenotype of allergy. Allergic subjects exhibit a predominance of allergen-specific Th2 cells, while tolerant non-allergic subjects exhibit a predominance of allergen-specific Treg cells.

[0108] In the majority of subjects, food tolerance occurs naturally. Upon initial encounter with an intestinal antigen, the predominant signals are provided by tolerogenic DCs, including pDCs, which are abundant in the intestine, and therefore the entire immune response is tolerance-specific. This initial tolerance response supports the ongoing commitment of tolerogenic DCs and sustains allergen-specific tolerance through the production of immune factors that lead to the further differentiation of allergen-specific naive T cells into Tregs upon each subsequent allergen encounter.

[0109] In individuals who are allergic to an allergen, natural processes involving tolerogenic DCs are inappropriately overridden by signals from activated DCs or other activated antigen-presenting cells (e.g., Langerhans cells), which alternatively direct the immune response to the allergen toward a Th2 allergic reaction, resulting in allergy to that allergen. This initial allergic response supports the continued involvement of activated DCs or activated antigen-presenting cells, and continues and sustains the allergy to the allergen by producing immune factors that drive further differentiation of allergen-specific naive T cells into Th2 cells upon each subsequent allergen encounter. The dominance of allergen-specific Th2 cells (over allergen-specific Treg cells) leads to the production of allergen-specific IgE antibodies and mast cells, key immune factors central to the manifestations of an allergic reaction. When an allergic subject is re-exposed to the allergen, the allergen binds to IgE antibodies on the surface of mast cells, and cross-linking of IgE antibodies bound to adjacent mast cells triggers the release of mediators, including histamine and leukotrienes, resulting in the symptoms of an allergic reaction.

[0110] Without wishing to be bound by theory, it is believed that adding live bacteria to peanut OIT induces an increase in the number of tolerogenic cells (e.g., pDCs), enabling subjects to acquire the ability to digest higher doses of peanut allergen during the dose-escalation phase without an increase in adverse events. One way this can be achieved is by pDCs supporting the differentiation of allergen-specific Treg cells, which then suppress the development of allergic responses resulting from exposure to peanut allergen during OIT. Furthermore, Tregs may inhibit intestinal inflammation, thereby limiting gastrointestinal symptoms resulting from peanut allergen exposure during OIT. Therefore, preferably, administration of live bacteria may stimulate the generation of tolerogenic DCs, or in other words, an increase in the number of tolerogenic DCs may be induced by or in response to the live bacteria. While this induction occurs in vivo, it may also be tested in vivo or in vitro.

[0111] Preferably, the tolerogenic DCs are plasmacytoid dendritic cells (pDCs). Data are presented in Example 2 demonstrating that a wide variety of probiotic bacteria, including Lactobacillus rhamnosus GG, Bifidobacterium lactis, Saccharomyces boulardi, E. coli Nissle 1917, Streptococcus thermophilus, and Bifidobacterium breve, induce pDCs, and that these probiotic bacteria represent particularly preferred probiotic bacteria for use in the treatments of the present invention. However, numerous other beneficial gut bacteria (probiotic bacteria) are expected to induce pDCs and could be used. The ability to induce pDCs is similar in allergic subjects and subjects with allergic diseases (such as asthma, allergic rhinitis, eczema or food allergies, FIG. 5).

[0112] Tolerogenic DCs have a half-life of approximately 14 days. Consequently, live bacteria, when administered, must be administered repeatedly throughout the oral immunotherapy regimen to ensure that the number of pDCs continues to increase and that they can induce Treg differentiation with specificity for the co-administered peanut allergen. Furthermore, live bacteria have been shown to only transiently colonize the intestine and are usually no longer detectable by two weeks after discontinuation of regular administration. Thus, the administration of live bacteria as described above herein is used, for example, as an oral administration at least once a week.

[0113] A procedure for testing live bacteria for their ability to induce tolerogenic DCs is outlined in Example 2, and representative data demonstrating the induction of tolerogenic DCs by several different live bacteria are presented. Briefly, a subject may be administered a dose of live bacteria daily for two weeks, and PBMCs may be isolated from blood samples taken from the subject before and after administration of the live bacteria and cultured in the presence or absence of heat-killed live bacteria, before staining the cells for one or more markers known to be associated with tolerogenic DCs and analyzing the proportion of DCs present in the cultured PBMCs. According to this procedure, the ability of live bacteria to induce pDC proliferation / differentiation / mobilization is demonstrated by an increase in the number of pDCs in cultures stimulated with heat-killed live bacteria on day 14 compared to day 0. The number of pDCs at each time point is calculated by subtracting the number of pDCs in unstimulated cultures from the number of pDCs in cultures stimulated with heat-killed live bacteria. Alternatively, fresh PBMCs can be used to directly test for pDCs when there is no need to culture the cells.

[0114] In a further preferred embodiment, the probiotic bacteria may be any probiotic microorganism of the species Lactobacillus, Bifidobacterium, Escherichia, Saccharomyces, Streptococcus or Bacillus. In a particularly preferred embodiment, the species is derived from Lactobacillus, Bifidobacterium, Saccharomyces or Streptococcus.

[0115] In one embodiment, the probiotic microorganism is a species of Lactobacillus selected from the list of Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus johnsonii, Lactobacillus lactis, Lactobacillus plantarum, Lactobacillus reuteri, Lactobacillus rhamnosus, Lactobacillus salivarius, and Lactobacillus helveticus.

[0116] In a particularly preferred embodiment, the probiotic bacteria may be Lactobacillus rhamnosus, and in particular Lactobacillus rhamnosus GG. In other embodiments, the probiotic bacteria may be Bifidobacterium lactis, Saccharomyces boulardi, E. coli Nissle 1917, Streptococcus thermophilus, or Bifidobacterium breve.

[0117] In some embodiments, the probiotic bacteria is a bacterial species selected from the group consisting of Clostridium bolteae, Anaeroturunccus colihominis, Sellimonas intestinales, Clostridium symbiosum, Blautia producta, Dorea longicatena, Erysipelotrichaceae bacteria, subdolinogranulum species, Ruminococcus torques, Clostridium innocuum, Flavinofractor plautii, and combinations thereof.

[0118] In some embodiments, the live bacteria are a complex microbial system, as described in U.S. Patent No. 10,265,349. In some embodiments, the complex microbial system comprises, in vivo: (i) a preparation of viable, culturable anaerobic intestinal bacterial strains that express exopolysaccharides, lipoteichoic acid (LTA), lipopolysaccharide (LPS), or other microbial adjuvant molecules that promote the development of regulatory T cells (Tregs); (ii) a preparation of viable, culturable anaerobic intestinal bacterial strains that produce butyrate and / or propionate fermentation products via fermentation of carbohydrates and other carbon sources in the intestinal lumen; (iii) one or more viable, culturable anaerobic intestinal bacterial strains that, alone or in combination, perform a full complement of bile acid conversion. (iv) a preparation of a viable, culturable anaerobic intestinal bacterial strain that produces a compound capable of stimulating the aryl hydrocarbon receptor (AhR) receptor pathway in intestinal epithelial cells, antigen-presenting cells, and / or T cells to stimulate the development of a regulatory T cell response; (v) a preparation of a viable, culturable anaerobic intestinal bacterial strain that produces a compound capable of stimulating the pregnane X receptor, which has beneficial effects on intestinal barrier function and / or the development of a regulatory T cell response; (vi) a preparation of a viable, culturable anaerobic intestinal bacterial strain that produces a compound capable of stimulating the pregnane X receptor, which has beneficial effects on intestinal antigen-presenting cells and / or epithelium. (vii) Preparations of viable and culturable anaerobic intestinal bacterial strains that stimulate the host production of mucins and complex glycoconjugates that improve intestinal barrier function and colonization by protective commensal species; (viii) Preparations of viable and culturable anaerobic intestinal bacterial strains that produce compounds capable of stimulating the ROR gamma (RAR-related orphan receptor gamma) pathway to stimulate the generation of regulatory T cell responses via direct stimulation or the ROR gamma activation pathway in cells, and subsequently stimulating regulatory T cell responses; (ix) preparations of viable and culturable anaerobic intestinal bacterial strains that modify the intestinal luminal environment to reduce the harmful activity of dysbiotic species that promote the development of a dysbiotic response; (ix) preparations of viable and culturable anaerobic intestinal bacterial strains that modify the intestinal luminal environment to promote improved colonization by other members of the administered consortium and / or colonization by existing beneficial species in the patient's underlying microbiota, for any of the effects defined above; (x) promoting colonization or growth of bacterial strains in the preparations (i) to (ix) above,It may also be a preparation of a viable and culturable strain of anaerobic enteric bacteria. In embodiments, the live bacteria are Eubacterium rectale, Clostridium ramosum, Butyrovibrio crossatus, Roseburia intestinalis, Clostridium hylemonae, Hungatella hathawayi, Clostridium symbiosum, Faecalibacterium prausnitzii, subdoligranulum variabile, Bacteroides spp., Bacteroides thetaiotaomicron, Bacteroides thetaiotaomicron, Bacteroides fragilis, Bacteroides ovatus, Parabacetroides goldsteinii, Parabacteroides merdae, Parabacteroides distasonis, Prevotella tannerae, Clostridium sardiniensis, Clostridium hiranonsis, Facealibacterium prausnitzii, Butyrovibrio spp., Eubacterium lectare rectale), Roseburia intestinalis, Clostridium scindens,Clostridium spp. (e.g., Clostridium ramosum, Clostridium scindens, Clostridium hiranonsis, Clostridium bifermentans, Clostridium leptum, Clostridium sardiniensis, Clostridium hathewayi, Clostridium nexile, Clostridium hylemonae, Clostridium glycyrrhizinilyticum, Clostridium labarens) lavalense, Clostridium fimetarium, Clostridium symbiosum, Clostridium sporosphaeroides, Prevotella copri, Prevotella paludivivens, and combinations thereof.

[0119] Administration of peanut allergens and live bacteria (if administered) is oral, i.e., delivered to the gastrointestinal tract via the mouth.

[0120] It is anticipated that, particularly with peanut allergen administration, each incremental dose will be administered in a clinical setting, such as a hospital, or under clinical supervision, but that daily dose interventions between dose increases may occur at home. This manner of allergen dose escalation is a common feature of OIT regimens in the field.

[0121] The timing of administration of the peanut allergen and / or live bacteria is discussed above. When a treatment includes administration of both a peanut allergen and live bacteria, the live bacteria and the allergen may be administered to a subject separately, sequentially, or simultaneously, when considered relative to each other. Thus, in certain embodiments of the present invention, each administration of the allergen, live bacteria, and allergen may be administered simultaneously, separately, or sequentially.

[0122] According to a preferred embodiment, the live bacteria and the allergen may be administered simultaneously in a single composition or as separate compositions.

[0123] According to certain embodiments of the invention, when the live bacteria and the allergen are administered in separate compositions and / or when the live bacteria and the allergen are administered sequentially, for each administration of the peanut allergen, the peanut allergen may be administered 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 10 minutes, 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours or more, up to 12 hours, before the live bacteria. According to alternative embodiments, the live bacteria may be administered 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 10 minutes, 30 minutes, 1 hour, 2 hours, 3 hours, 4 hours, 5 hours, 6 hours, 7 hours, 8 hours, 9 hours, 10 hours, 11 hours or more, up to 12 hours, before the allergen.

[0124] According to further embodiments of the present invention, the split and / or sequential administration of live bacteria and allergen may include administering each of the two components at an interval of more than 12 hours. Thus, according to certain embodiments of each administration of allergen, the allergen and live bacteria may be administered separately at an interval of up to 7 days, more preferably at an interval of up to 6, 5, 4, 3, 2, or 1 day. In certain embodiments of each administration of peanut allergen, the live bacteria may be administered at an interval of up to 7, 6, 5, 4, 3, 2, or 1 day before the allergen. According to other embodiments of each administration of allergen, the allergen may be administered at an interval of up to 7, 6, 5, 4, 3, 2, or 1 day before the live bacteria.

[0125] As referred to herein, "each" administration of an allergen refers to each dose of the allergen administered to a subject. However, this does not mean that a corresponding dose of live bacteria is administered for each dose of the allergen (if the treatment requires the administration of a peanut allergen and live bacteria). Instead, each allergen dose is related to a dose of live bacteria, which is applied to this dose in the administration schedule discussed. Thus, for example, a single live bacteria dose may be a dose related to two or more allergen administrations, resulting in administration within the time constraints discussed herein. During the acute phase, for example, multiple doses of the allergen may be administered in addition to only a single dose of live bacteria. This is possible because the effect of the live bacteria is maintained over the period of multiple allergen administrations. Thus, according to certain exemplary embodiments, assuming that live bacteria are administered to a subject at least weekly in accordance with the treatment described herein, one or more doses of the allergen may be administered separately or independently from the live bacteria (e.g., after the live bacteria).

[0126] The term "allergen," as used herein, refers to a substance capable of inducing an allergic response, particularly the production of antibodies against the allergen, typically, but not exclusively, immunoglobulin E (IgE), as allergens may also induce allergic responses that are non-IgE mediated. An immune response in which IgE is produced may also be referred to as a Type I hypersensitivity response or an "IgE-mediated allergic response" or "IgE-mediated allergic response." An allergic response in which IgE is not produced or is not the primary cause of symptoms may also be referred to as a "non-IgE-mediated allergic response" or a "mixed IgE / non-IgE-mediated allergic response."

[0127] An "allergic subject" is a subject that produces an allergic response when exposed to an allergen. Allergic individuals may vary in the amount of allergen that will cause an allergic reaction, and the threshold dose at which an allergic reaction is induced in an individual is called the response-inducing dose. The response-inducing dose of an allergic individual may sometimes vary (by several fold) depending on various host or environmental factors, such as having concurrent illnesses, asthma exacerbation, allergic rhinitis symptoms, or exercising within a few hours of allergen ingestion, but generally does not change dramatically. In a preferred embodiment, the threshold for a response to a peanut allergen in an allergic subject is an allergen equivalent to 50 mg or less, preferably 100 mg, 300 mg, 500 mg, or 600 mg or less of peanut protein in a single dose.

[0128] An individual's reaction-inducing dose (threshold for a reaction to a peanut allergen) may be assessed by conducting a food challenge involving oral administration of increasing doses of peanut allergen at regular intervals. The dose at which an individual has an allergic reaction is identified as the reaction-inducing dose in that individual. Thus, for example, the dose of peanut allergen at which a subject experiences an allergic reaction may be assessed by conducting a food challenge and observing the subject for a reaction within 2 hours of challenge administration. Typically, the reaction will occur within 15 to 20 minutes of administration of the allergen. Symptoms of the reaction may include hives, swelling, itching, vomiting, abdominal pain, wheezing, stridor, difficulty breathing, paleness / listlessness in infants or children, hypotension, and collapse. Criteria for identifying reactions during food challenge are presented in the American Academy of Allergy, Asthma and Immunology-European Academy of Allergy and Clinical Immunology PRACTALL consensus document.

[0129] A peanut allergen is a component of peanuts that acts as an allergen in a subject allergic to it (i.e., an allergic subject), and the subject will typically suffer an adverse response to it when exposed to a sufficient amount of the peanut allergen. Typically, a peanut allergen is a protein found in peanuts, or more specifically, an antigen found in a protein found in peanuts. Even more specifically, an allergen may be a specific epitope in such a protein. Thus, the term "peanut allergen" encompasses any proteinaceous substance that can elicit an allergic response in a subject with a peanut allergy. According to certain embodiments of the present invention, a peanut allergen may be, be present in, or be derived from a peanut protein. As referred to herein, an allergen "derived from" is one that is obtained from a peanut protein and, optionally, is modified but still retains the allergic epitope.

[0130] References herein to a "peanut allergen" encompass one or more peanut allergens, noting that peanuts contain multiple peanut allergens.

[0131] A peanut allergen may be a protein (or antigen or epitope) naturally found in peanuts. Thus, for convenience, the allergen may be provided as a peanut protein, for example, in the form of peanuts, a food containing peanuts such as peanut butter, or more preferably, in the form of peanut flour or a defatted or partially defatted form thereof.

[0132] Certain peanut proteins are known to be associated with peanut allergies. In other words, subjects with peanut allergies may typically be allergic due to an immune response to one or more specific proteins found in peanuts. Without wishing to be bound by theory, such subjects may have high levels of IgE, particularly to one or more epitopes present in peanuts. According to certain embodiments of the present invention, the peanut allergen may be one or more of Ara h1 to Ara h9. More preferably, the peanut allergen may be one or more of Ara h1, h2, h3, h6, h8, or h9, which are considered particularly common allergens in subjects suffering from peanut allergies. Even more preferably, the peanut allergen may be Ara h2. In treatment (e.g., by using peanut flour), multiple allergens may be used, and the subject may be allergic to one or more of the allergens so present.

[0133] However, according to further embodiments, the peanut allergen may be derived from a peanut protein, such as a modified peanut protein (i.e., a modified form of a peanut protein), and so in particular embodiments the peanut allergen may be a modified form of a peanut protein, more particularly a modified form of the particular peanut proteins outlined above.

[0134] According to certain embodiments, the modified peanut protein may be a modified peanut protein. Such a protein, although modified compared to a protein naturally found in peanuts, may still be an allergen when a subject suffering from peanut allergy is allergic to it and may be used in the treatment of the present invention. Thus, according to certain embodiments, the modified peanut protein may contain one or more amino acid insertions, deletions, and / or substitutions compared to a protein naturally found in peanuts, and / or may be provided in the form of a fusion protein comprising a peanut protein linked to a second polypeptide that is not a peanut protein. Alternatively or additionally, the modified peanut protein may be a fragment of a peanut protein, i.e., a polypeptide derived from a peanut protein, such as those defined above. According to further embodiments, the peanut protein (or a modified form thereof) may be recombinantly expressed in a genetically modified host cell comprising a nucleotide sequence encoding the peanut protein, and preferably isolated or purified therefrom before administration to a subject in the treatment of the present invention.

[0135] According to other embodiments, peanut allergens (more specifically, when provided as peanuts or groundnut flour as defined herein) may undergo one or more processing steps before administration to a subject. For example, peanut allergens may undergo one or more enzymatic treatments. Enzymatic treatment with proteases, such as trypsin or elastase, has been shown to reduce the allergenicity of certain nuts and their IgE-binding capacity, and after hydrolysis with the endoprotease alcalase, the binding of the soluble peanut fraction to IgE is reduced. Thus, peanut allergens may be partially hydrolyzed peanut proteins. Alternatively or additionally, peanut allergens may undergo acid treatment (e.g., acetic acid at a pH of 1.0 or about 1.0), preferably at a pH of less than 3.0, and / or heat treatment, for example, by roasting, boiling, or frying.

[0136] To standardize the treatment of the present invention, reference is made herein to an "allergen equivalent" dose for a specific mass of peanut protein. As referred to herein, peanut protein refers to the amount of peanut protein present in the immunotherapy reagent. Peanut protein is the total protein content of peanuts, and includes all allergenic peanut proteins, including Ara h1-h9. The amount of the product to be used in accordance with the present invention is based on allergen equivalent, i.e., determined to obtain the same amount of allergen as is present in a specified dose.

[0137] When a subject is allergic to more than one peanut allergen, preferably all peanut allergens to which the subject is allergic are administered, in which case the allergen equivalent dose of peanut protein corresponds to a product containing the same amount of all of the relevant allergens in that dose.

[0138] The peanut allergen may be administered in the form of whole or partial peanuts, or may be extracted, isolated, and / or purified from peanuts. Preferably, the peanut protein is provided as a peanut extract, such as peanut flour. Preferably, the flour is a powder containing about 50% peanut protein and about 3.5% moisture.

[0139] Peanut flour is produced by crushing, grinding, and / or milling whole peanuts. Wheat flour may be partially or fully defatted to reduce the fat content. Defatting does not affect the allergenic peanut protein content of the flour. Peanut flour may be purchased from Byrd Mill (Ashland, VA, USA) or other similar suppliers. The peanut flour may be about 10% to about 15%, or about 12%, defatted peanut flour milled from lightly roasted peanuts.

[0140] Thus, reference to the equivalent of a dose of peanut protein includes the amount of peanut protein allergen in purified, substantially purified, or isolated form, or when incorporated as part of a substance such as a food, biological system, or chemical composition. Peanuts are widely known to contain approximately 25% w / w peanut protein, while peanut flour is known to contain approximately 50% w / w peanut protein (although the exact value may vary depending on factors such as the source of the peanut allergen and whether the peanut allergen has been processed in any way). The peanut protein content of peanut flour may be readily determined using standard techniques. A peanut allergen dose of 2000 mg peanut protein may be equivalent to approximately 8000 mg peanuts (approximately 8-10 peanuts).

[0141] Additionally, other peanut extracts containing peanut protein may be used in the methods described herein, hi some embodiments, whole peanut protein may be isolated and / or purified from other components of peanuts for use as described herein.

[0142] In some embodiments, the peanut protein may be administered as whole peanuts, which may be preferable, for example, for higher escalating doses, such as 400 mg and 800 mg or more of peanut protein.

[0143] Peanut OIT doses may be prepared under GMP conditions by Optima Ovest (Malaga, Australia) or other similar facilities. For example, peanut flour may be provided as set doses in capsules (for doses of 200 mg or less), sachets (for doses of 400 mg to 1600 mg), and peanut flour tablets with standardized measuring scoops (for doses of 200 mg or more).

[0144] Conveniently, the peanut allergen (optionally in the form of whole peanuts or peanut flour as outlined above) may be provided without or mixed with a carrier to provide a composition for administration to a patient. Suitable whole peanuts include roasted peanuts, including salted and honey-roasted, and coated or embedded peanuts in any form, such as peanuts coated or embedded in food products, for example, chocolate or yogurt. Conveniently, ground nuts may also be used inside or present in food products, such as biscuits, cakes, chocolates, sweets, or jams, or sprinkled on yogurt (which may not, according to certain embodiments, contain live bacteria, such as L. rhamnosus GG).

[0145] When used, a suitable carrier acts to shield the peanut allergen (especially when in the form of peanut flour) from the mouth and upper gastrointestinal tract, reducing or preventing swelling and / or irritation in these areas during treatment. For example, the carrier may contain one or more lipid, carbohydrate, or protein components. In certain embodiments, the carrier may be a food product (i.e., the peanut allergen may be administered into or on said food product), such as a dairy product or dairy substitute product (e.g., a corresponding soy-based product), such as yogurt, milkshake, or chocolate, or may be provided in other foods such as applesauce or pudding. For example, the peanut allergen may be provided as a powder or sprinkle to be added to such foods.

[0146] Alternatively, the peanut allergen may be provided in a composition for oral delivery, such as capsules, sachets, or tablets, each containing a predetermined amount of the peanut allergen, to provide a precise dose to a patient or subject. Oral delivery compositions may be useful, for example, to avoid contact between the peanut allergen and the mouth and upper gastrointestinal tract.

[0147] Peanut allergen composition In some embodiments, the peanut allergen or peanut protein is administered as a pharmaceutical composition. In some embodiments, the pharmaceutical composition comprises peanut flour and other pharmaceutically acceptable carriers. To prepare oral delivery compositions, pharmaceutically acceptable carriers, binders, fillers or diluents, lubricants, and preservatives may be used and are well known in the art. "Pharmaceutically acceptable," as referred to herein, refers to a component that is compatible with other ingredients of the composition (or product) and physiologically acceptable to the recipient. Pharmaceutical compositions may be used in the treatments described herein.

[0148] In some embodiments, the peanut allergen composition comprises peanut flour containing peanut protein, which may be Ara h1, Ara h2, Ara h3, Ara h4, Ara h5, Ara h6, Ara h7, Ara h8, Ara h9, and combinations thereof, or equivalent allergens.

[0149] In some embodiments, the peanut allergen composition contains peanut protein or a corresponding allergen in an amount of about 0.1 mg to about 2000 mg, about 0.1 mg to about 1500 mg, about 0.1 mg to about 1000 mg, about 0.1 mg to about 500 mg, about 0.1 mg to about 250 mg, about 0.1 mg to about 100 mg, about 0.1 mg to about 50 mg, about 0.1 mg to about 10 mg, or about 0.1 mg to about 2 mg, about 0.1 mg to about 1 mg, or about 0.1 mg to about 0.4 mg. Specific examples include about 0.1 mg, about 0.4 mg, about 0.5 mg, about 1 mg, about 2 mg, about 10 mg, about 100 mg, about 500 mg, about 1000 mg, about 2000 mg, and ranges between any of these values.

[0150] In some embodiments, the peanut allergen composition comprises peanut flour (having about 50% protein content) in an amount of about 1% to about 70% w / w, about 1% to about 60% w / w, about 1% to about 50% w / w, about 1% to about 40% w / w, about 1% to about 30% w / w, about 1% to about 15% w / w, about 1% to about 10% w / w, about 5% to about 70% w / w, about 8% to about 15% w / w, or about 9% to about 12% w / w.

[0151] Live bacteria composition When used, in some embodiments, the probiotic microorganisms disclosed herein are formulated into pharmaceutical compositions, which may include pharmaceutically acceptable excipients such as sterile water, saline, solvents, bases, emulsifiers, suspending agents, surfactants, stabilizers, flavoring agents, fragrances, excipients, vehicles, preservatives, binders, diluents, isotonicity agents, soothing agents, bulking agents, disintegrants, buffers, coating agents, lubricants, coloring agents, sweeteners, thickeners, and solubilizers.

[0152] In some embodiments, the live microorganisms are present in the composition as freeze-dried, spray-dried, spore form, or vegetative form.

[0153] In some embodiments, the probiotic composition may further comprise a short chain fatty acid or a derivative thereof, a GPR109A ligand, a GPR43 ligand, an HDAC inhibitor, and combinations thereof.

[0154] In some embodiments, the probiotic composition comprises a short chain fatty acid or a short chain fatty acid derivative selected from the group consisting of butyric acid, isobutyric acid, propionic acid, acetic acid, tributyrin, pivaloyloxymethyl butyrate, and monoacetone glucose 3-butyrate, and combinations thereof.

[0155] In some embodiments, the live bacterial composition comprises a ligand that binds to the G protein-coupled receptor GPR109A. Non-limiting examples of GPR109A ligands include pyridine-3-carboxylic acid (also known as niacin or vitamin B3), niacin derivatives, 4,5-dihydro-5-methyl-4-oxo-5-phenyl-2-furancarboxylic acid, 5-carboxy-2-methyl-1-oxidopyrazin-1-ium, GSK-256073, GSK256073, ARI-3037MO, INCB019602, INCB19602, MK-0354, MK-0354, barbituric acid derivatives, anthranilic acid derivatives, pyrazole derivatives, isoxazole derivatives, xanthine derivatives, cycloalkane derivatives, pyrazolopyrimidines, thiophenes, and combinations thereof.

[0156] In some embodiments, the live bacterial composition comprises a ligand that binds to the G protein-coupled receptor GPR43. Non-limiting examples of GPR43 ligands include acetic acid, formic acid, phenylacetamide 1 [(S)-2-(4-chlorophenyl)-3-methyl-N-(thiazol-2-yl)butanamide], phenylacetamide 2 [(S)-2-(4-chlorophenyl)-N-(5-fluorothiazol-2-yl)-3-methylbutanamide], propionic acid, valeric acid, and combinations thereof.

[0157] In some embodiments, the probiotic composition comprises an HDAC inhibitor selected from trichostatin A, (N-(2-aminophenyl)-N'-phenyl-octanediamide), 2-(4-butoxyphenyl)-N-hydroxyacetamide, MS-275, suberoylanilide hydroxamic acid, RG2833, and combinations thereof.

[0158] In some embodiments, the live bacterial composition comprises antigens purified from a bacterial strain belonging to Clostridium cluster IV, Clostridium cluster XIVa, or Clostridium cluster XVIII.

[0159] The probiotic compositions disclosed herein are formulated for oral administration in the form of capsules, tablets, pills, sachets, liquids, powders, granules, fine granules, film-coated formulations, pellets, chewable tablets, pastes, syrups, suspensions, elixirs, emulsions, and the like.

[0160] In some embodiments, the probiotic composition is formulated for delivery to the intestine. In some embodiments, the probiotic composition is formulated for delivery to the colon.

[0161] Furthermore, the live bacteria may be administered through food, or more preferably, in a beverage. Therefore, the live bacteria may be preferably administered in water, cow's milk or soy milk, or other milk or beverage. The live bacteria may be provided as a set dose, for example, in capsules or tablets with a standardized measuring scoop. Lactobacillus rhamnosus GG (LGG) may be obtained from Chr Hansen (Denmark).

[0162] Additional medications may be used during treatment to support treatment. For example, the live bacterial composition may be administered with prebiotics known to support the growth of live bacterial cells. In any of the methods described herein, one or more antibiotics may be administered to the subject prior to administration of any of the live bacterial or peanut allergen compositions described herein.

[0163] In further embodiments, other drugs may be used during treatment, such as anti-allergy drugs, for example, antihistamines, steroids, bronchodilators, leukotriene stabilizers, and mast cell stabilizers. Suitable anti-allergy drugs are well known in the art. Such drugs may be useful in reducing allergic inflammation and increasing tolerance to allergens.

[0164] In some embodiments, administration of a composition disclosed herein results in the suppression of IgE antibody production. In some embodiments, administration of a composition described herein results in enhanced proliferation and / or accumulation of regulatory T cells (e.g., total Tregs or allergen-specific Tregs) in a subject. In some embodiments, administration of a composition described herein results in enhanced proliferation and / or accumulation of regulatory T cells (e.g., total Tregs or allergen-specific Tregs) at a specific site (e.g., the gastrointestinal tract) in a subject. In some embodiments, administration of a composition described herein results in enhanced activity of regulatory T cells.

[0165] In some embodiments, administration of a composition described herein results in at least a 1.1-fold, 1.2-fold, 1.3-fold, 1.4-fold, 1.5-fold, 2-fold, 3-fold, 4-fold, 5-fold, 6-fold, 7-fold, 8-fold, 9-fold, 10-fold, 20-fold, 30-fold, 40-fold, 50-fold, 100-fold, 1000-fold or more increase in the expansion and / or accumulation of regulatory T cells (e.g., total Tregs or allergen-specific Tregs) compared to the amount of regulatory T cells in the subject (or at a particular site in the subject) before administration of the composition.

[0166] In some embodiments, the compositions and methods described herein suppress one or more Th2 immune responses. In some embodiments, the compositions and methods described herein suppress the development or differentiation of Th2 cells (also known as type 2 helper T cells). In some embodiments, the compositions and methods described herein suppress the activity of Th2 cells. As will be apparent to one of skill in the art, Th2 cells are the counterpart of CD4+ cells that produce IL-4, IL-5, IL-6, IL-10, and / or IL-13, and may be involved in promoting IgE antibody responses and / or eosinophil activity.

[0167] A subject as referred to herein refers to an animal, particularly a mammal, more particularly a human, having an allergy to an allergen, who may benefit from the treatment of the present invention. In particularly preferred embodiments, the subject may be an adult. Preferably, however, the subject is not an adult; in certain embodiments, the subject may be under 18 years of age, i.e., the subject may be a child. Even more preferably, the subject may be a child under 12 years of age, or a child under 6 years of age. In further embodiments, the subject may be 6 years of age, e.g., 12 or 18 years of age, or in other embodiments, 5 to 10 years of age. In particularly preferred embodiments, the child may be 1 month to 10 or 12 years of age. In particularly preferred embodiments, the child is under 10 years of age, under 5 years of age, or 1 to 5 years of age.

[0168] The methods described herein may be used with any patient with a peanut allergy and are independent of the patient's sensitivity or challenge threshold to the allergen, the patient's weight or height, and other factors.

[0169] In the process of developing the present invention, it has been unexpectedly found that the dose of peanut allergen can be increased more rapidly than previously described in the art, and the time required to reach the maintenance dose in oral immunotherapy regimen can be reduced without increasing side effects, and the time required to reach the same maintenance dose can be reduced, improving the odds of a subject achieving sustained unresponsiveness.In particular, it has been found that the time required to reach the maintenance dose is reduced by one week compared to oral immunotherapy regimen with a longer dose escalation period, and the odds of achieving sustained unresponsiveness are increased by about 9-11%.Therefore, according to certain embodiments, the ability to reach the maintenance phase in a reduced time period compared to immunotherapy regimen with a longer dose escalation period improves the odds of achieving sustained unresponsiveness.

[0170] In other words, a reduction in the time to reach the maintenance dose compared to the time it takes to reach the maintenance dose in an oral immunotherapy regimen that uses a longer dose escalation period to reach the same maintenance dose improves the odds that a subject will achieve sustained unresponsiveness. In particular, reaching the maintenance dose in 24 weeks or less, or more specifically 23 weeks, 22 weeks, 21 weeks, or 20 weeks or less improves the odds that a subject will achieve sustained unresponsiveness compared to an oral immunotherapy regimen that uses a longer dose escalation period to reach the same maintenance dose.

[0171] As referred to herein, the "odds of achieving sustained unresponsiveness" provide an indication of the probability that a subject will achieve sustained unresponsiveness as a result of the treatment of the present invention. For each subject receiving the treatment (or prior art treatment), the odds that they will achieve sustained unresponsiveness can be determined based on data generated from a population of individuals receiving the treatment to which the new subject will be subjected. The data allows for the determination of the proportion of individuals within the population achieving sustained unresponsiveness, and thus the probability that any new subject may achieve sustained unresponsiveness. Preferably, with each week that the dose escalation phase is reduced (e.g., from 26 weeks to 24 weeks or from 32 weeks to 24 weeks), the odds of sustained unresponsiveness increase for each week of reduction, preferably by at least 5%, preferably by 5-10%, and more preferably by about 7.5%.

[0172] The present invention relates to the surprising effect that the rate of adverse events suffered by subjects during the oral immunotherapy regimen of the present invention is comparable (or lower) to the rate of adverse events suffered by subjects in the oral immunotherapy regimen of the present invention, which includes the administration of peanut allergen OIT alone or live bacteria and peanut allergen, and which uses a longer dose escalation period and a longer period until the maintenance phase is reached.Therefore, this brings the benefit that subjects receiving the present invention's treatment will no longer suffer (or suffer less) adverse events during the accumulation phase, even if the allergen dose increases more rapidly in the present treatment.Oral immunotherapy regimens typically require that the increase in the allergen dose be delayed if adverse events are observed (i.e., when a certain dose should be administered for a longer period).When the treatment does not induce any additional adverse effects compared to the known method, the treatment can be easily carried out according to the above protocol.

[0173] In a further embodiment of the invention, the treatment may be administered to a population of subjects. As described herein, the population may be at least 5 individuals, such as at least 10 or 20 individuals, for example 5-20 individuals.

[0174] Thus, according to a further aspect, the present invention provides a peanut allergen for use in the treatment of peanut allergy in a population of subjects, wherein the treatment comprises an oral immunotherapy regimen in which the peanut allergen is administered in escalating doses from an initial dose of the allergen equivalent to 5 mg or less of peanut protein to a dose of the allergen equivalent to 200 mg or more of peanut protein within 4 to 9 weeks of administration of the initial dose, and wherein the peanut allergen is administered orally, the treatment comprising an escalating dose phase.

[0175] In a preferred embodiment, live bacteria are provided to be administered orally at least once weekly during the peanut allergen dose escalation phase.

[0176] In a preferred embodiment, the live bacteria, the peanut allergen, the subject and / or the oral immunotherapy regimen are as defined above.

[0177] Preferably, in said population, said dose escalation from an allergen equivalent to 5 mg or less of peanut protein to an allergen equivalent to 200 mg or more of peanut protein is achieved in more than 25% of the population (e.g. more than 30%, 40%, 50%, 60%, 70%, 75%, 80%, 85%, 90% or 95%, e.g. 50-75%) within 4 to 9 weeks of administration of the initial dose. Preferably, the same percentage of the population achieves other specified doses (including preferred doses as defined herein above) at specified time intervals (including preferred time periods as defined herein above).

[0178] Alternatively, preferably, the median time for a population to achieve said dose escalation from 5 mg or less of allergen equivalent to peanut protein to 200 mg or more of allergen equivalent to peanut protein is 4 to 9 weeks from administration of the initial dose. Preferably, other median time periods (including preferred time periods as described herein) are achieved by populations at other prescribed doses (as described herein above).

[0179] Following the surprising discovery that a shorter accumulation phase may result in an increased likelihood of persistent unresponsiveness, no increased likelihood of adverse events, particularly moderate to severe adverse events, or a combination thereof, disclosed herein are improved oral immunotherapy regimens for treating peanut allergy in subjects in need thereof, including a reduced time frame for the accumulation phase when compared to the prior art.

[0180] The accumulation phase in the prior art is much slower / longer than that of the present invention. An exemplary prior art accumulation phase in peanut + live bacteria OIT is described in Tang et al., J Allergy Clin Immunol 135(3):737-744, 2015, and is shown below.

[0181] [Table 1]

[0182] During the accumulation phase, peanut protein is administered orally to subjects in need thereof once daily, starting at approximately 24 mg on day 1, then increasing to 25 mg the following day, and thereafter increasing every two weeks until a maintenance dose is reached, as shown in Table 1.

[0183] A further example of a prior art accumulation phase without live bacteria is found in the PALISADE trial (Vickery 2018 NEJM, supra), where the accumulation phase of OIT treatment lasted 26 weeks until a dose of 300 mg was reached.

[0184] In contrast, embodiments of the present invention are directed to methods of treating peanut allergy in a subject in need thereof, utilizing an accumulation period of about 9 weeks to about 24 weeks, preferably about 16 weeks, to achieve a dose of 2000 mg, as described below.

[0185] [Table 2]

[0186] As used herein, the term "about," when immediately preceding a numerical value, means a range of ±10% of the value unless the context of this disclosure indicates otherwise or if there is a contradiction in such interpretation. For example, "about 50" means 45 to 55, and "about 25,000" means 22,500 to 27,500.

[0187] The transitional term "comprising," which is synonymous with "including," "containing," or "characterized by," is inclusive or open-ended and does not exclude additional, unrecited elements or method steps. In contrast, the transitional phrase "consisting of" excludes any element, step, or ingredient not specified in the claim. The transitional phrase "consisting essentially of" limits the scope of a claim to particular materials or steps and those that do not materially affect the basic and novel characteristics of the claimed invention. In embodiments or claims where the term "comprising" is used as the transitional phrase, such embodiments are also contemplated when the term "comprising" is replaced with the term "consisting of" or "consisting essentially of."

[0188] The methods described in the examples form further preferred aspects of the invention. All combinations of the preferred features described above are contemplated, particularly as described in the examples.

[0189] BRIEF DESCRIPTION OF THE DRAWINGS The invention will now be described, by way of non-limiting example, with reference to the following figures: [Brief explanation of the drawings]

[0190] [Figure 1A] Time in weeks to reach the 2000 mg peanut protein maintenance dose is shown as median and interquartile range for the standard versus rapid loading schedule. *P<0.05, ****P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 1B]The percentage of times the accumulation phase lasted longer than the expected 32 weeks for the standard accumulation schedule and the expected 16 weeks for the rapid accumulation schedule are shown as median and interquartile range, comparing the standard accumulation schedule with the rapid accumulation schedule. *P<0.05, ****P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 2A] The number of delayed build-up visits is shown as median and interquartile range for the standard and rapid build-up schedules. *P<0.05, **P<0.01, P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 2B] Percentage of visits in the delayed accumulation phase are shown as median and interquartile range for the standard accumulation schedule and the rapid accumulation schedule. *P<0.05, **P<0.01, P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 2C] The number of days of dose lag is shown as median and interquartile range for the standard and rapid-accumulation schedules. *P<0.05, **P<0.01, P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 3A] Cumulative doses received during accumulation are plotted by median and interquartile range. *P<0.05, ****P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 3B] The mean dose taken each week is plotted with median and interquartile range. *P<0.05, ****P<0.0001. The Mann-Whitney test was used to determine statistical differences. [Figure 4] The numbers of participants with moderate and severe adverse events (AEs) on the standard accumulation schedule and the rapid accumulation schedule during the ramp-up day and ramp-up phase are shown. Different shading indicates how many participants experienced a specific number of moderate to severe AEs. [Figure 5]Percentage of pDCs before and after 14 days of treatment with live bacteria in adults with allergic disease (n=58) and adults without allergic disease (n=62) is shown. The Mann-Whitney test was used to determine statistical differences between subjects with and without allergic disease, and the Wilcoxon matched-pairs signed-rank test was used to determine statistical differences between subjects evaluated on day 0 or day 14. DETAILED DESCRIPTION OF THE INVENTION

[0191] Example Example 1 - Comparison of outcomes in a protocol with a standard time to maintenance dose (PPOIT-001) and a protocol with a reduced time to maintenance (PPOIT-002) In this example, peanut OIT protocols were compared, using a standard administration protocol (PPOIT1) and a protocol with a reduced time to maintenance dose of OIT (PPOIT2).

[0192] Materials and Methods Study population In the PPOIT-001 study, 62 peanut-allergic children aged 1 to 10 years were given 2 × 10 live Lactobacillus rhamnosus GG (peanut OIT) supplements immediately before ingestion. 10 The study enrolled 20 peanut-allergic children in a randomized, double-blind, placebo-controlled trial of peanut-based OIT (a single daily dose of 2 × 10 cfu) combined with peanut OIT, consisting of an initial 8-month dose-escalation phase with a ramp-up period followed by an accumulation phase (up to 32 weeks of maintenance). In PPOIT-002, 20 peanut-allergic children were treated with live Lactobacillus rhamnosus GG (2 × 10 cfu) before ingestion of peanut OIT. 10 cfu daily) and peanut OIT, with a shortened dose-escalation phase of 4 months (to 16 weeks of maintenance).

[0193] Children enrolled in the PPOIT-001 trial were 1 to 10 years of age with a confirmed diagnosis of peanut allergy as defined by either a positive food challenge to peanut and a positive SPT or CAP-RAST to peanut within the past 2 years, or a history of a previous positive food challenge or reaction to peanut and a positive SPT ≥ 8 mm or CAP-RAST ≥ 15 U / l to peanut.

[0194] Children enrolled in the PPOIT-002 trial were 1 to 12 years of age with a confirmed diagnosis of peanut allergy as defined by failure of DBPCFC to peanut and a positive SPT or sIgE to peanut at screening or in the preceding 3 months.

[0195] Testing Participants in the PPOIT-001 study were randomized to receive either peanut OIT with live L. rhamnosus bacteria or placebo. In PPOIT-002, all participants received active treatment. Treatment began on the ramp-up day (day 0), and the ramp-up schedule was the same for both studies, as shown in Table 3. Before the ramp-up phase began, participants received a single dose of live bacteria or placebo (one scoop dissolved in water). Participants then received increasing doses of peanut (or placebo OIT) sprinkled on their food every 30 minutes until a final dose of 12 mg of peanut protein was reached (a cumulative dose of 24 mg of peanut protein or placebo). If a participant responded to one of the doses during the ramp-up phase, the ramp-up schedule ended, and the accumulation phase began the day after the ramp-up day (i.e., day 1) at a dose just below the ramp-up day's induction dose. Any remaining bolus doses not completed on day 0 were incorporated into the accumulation phase, and subsequent dose escalation proceeded through all remaining doses on the bolus schedule and subsequent doses on the accumulation schedule.

[0196] The load phase followed the crash day. The two different load schedules for PPOIT-001 and PPOIT-002 are shown in Tables 4 and 5. During the load phase, the daily dose of peanut OIT or placebo was increased every two weeks until a maintenance dose of 2 g was reached. Peanut protein or placebo was consumed by sprinkling on food, and the dose of live bacteria or placebo was mixed with water and consumed immediately before the OIT or placebo. Each dose increase was performed under medical supervision in a hospital setting.

[0197] Dose adjustment rules were similar in both studies and included guidelines for what dose should be continued if a participant reacted to a dose. If the reaction was mild or moderate (not anaphylactic) and occurred within 3 days of the scheduled dose increase, the dose increase would be postponed and the dose would be repeated before the increase; or, if the reaction occurred more than 4 days before the scheduled dose increase, the dose increase would proceed according to protocol. If an anaphylactic reaction occurred, the next-to-next dose would be reduced to the previous dose and continued for at least 10 days before proceeding with the dose increase. If a severe anaphylactic reaction (e.g., drop in blood pressure or loss of consciousness) occurred, OIT would be discontinued. The time it took each subject to reach each dose under the PPOIT-002 schedule is shown in Table 11.

[0198] An adverse event (AE) was defined as any untoward medical occurrence in a participant not necessarily related to the study drug. Details about each AE were prospectively collected and documented at each study visit or when prompted by the patient in their study diary throughout the study. Information included a description of the event, the onset and cessation dates of the event, the severity of the event, and any suspected relationship to study treatment. In the PPOIT-001 study, all reactions meeting the definition of anaphylaxis (any reaction involving the airway or circulation, regardless of severity) were initially classified as serious adverse events (SAEs). Recently, the NIH / NIAID Consortium of Food Allergy Research (CoFAR) developed a standardized tool for the classification of allergic reactions. This tool was adopted in the PPOIT-002 study and later applied to reclassify allergic AEs from PPOIT-001, allowing for a direct comparison of AE events in the two studies.

[0199] The CoFAR classification assigns a staging of anaphylactic events from moderate or severe to very severe, and only immediately life-threatening reactions are classified as SAEs.

[0200] Briefly, the CoFAR tool grades events from 1 to 5, where grade 1 events are mild and may include itching, swelling, or rash or abdominal discomfort; grade 2 events are moderate and may include persistent hives, wheezing without dyspnea or abdominal discomfort / increased vomiting; grade 3 events are severe and may include bronchospasm with dyspnea, severe abdominal pain, pharyngeal tightness with hoarseness, and transient hypotension; grade 4 events are life-threatening; and grade 5 events result in death. Grades 4 and 5 were categorized as SAEs. The correlation of the AEs to the study product was assessed using categories of probably related, possibly related, unlikely related, and unrelated.

[0201] When assessing AEs, all randomized participants were included, regardless of when or if they were withdrawn from the study. AEs classified as unrelated to or unlikely to be related to the study product were excluded from the analysis of this study. The comparison between PPOIT-001 and PPOIT-002 included exclusively moderate and severe AEs and SAEs. Two assessors reviewed the raw AE data from both the PPOIT-001 and PPOIT-002 studies and applied a tool developed by CoFAR to grade the severity and attribution of each event. The classifications were then compared, and if consensus was reached, the classification was approved. If consensus was not reached, a third-party independent assessor reviewed and provided a final assessment.

[0202] [Table 3]

[0203] [Table 4]

[0204] [Table 5]

[0205] calculation The dates of a participant's rapid day visit and subsequent accumulation phase visits were used to calculate the time to reach the maintenance phase and the number of days for each dose. Time to reach maintenance was expressed as a percentage of the optimal schedule according to the protocol and was calculated by dividing each participant's actual time to reach the maintenance phase by the optimal number of weeks they should have taken to progress through the accumulation protocol without deviation due to response or other reasons. The denominator was 32 weeks in the PPOIT-001 group and 16 weeks in the PPOIT-002 group. The number of delayed accumulation phase visits was extracted from the data by coding any number of days over the 14 days of dosing, which would indicate a delayed accumulation phase visit. The number of delayed accumulation phase visits as a percentage of the total number of accumulation phase visits was calculated by dividing the number of delayed accumulation phase visits by the total number of accumulation phase visits the participant had. The number of delayed days was calculated by adding the total number of days over the 14 days of dosing for each participant together to the total number of delayed days. Information on the dose on the bolus day, the number of days to dose, and the number of dose failures was used to calculate the total cumulative dose taken during the bolus day and the accumulation phase for each participant. To calculate the average dose taken by a participant during each week of the accumulation phase, the cumulative dose was divided by the number of weeks the participant was in the accumulation phase. The number of AEs, their characteristics, severity grade, and relationship to study product were collected from the AE database.

[0206] statistical analysis Statistical analysis was performed using Graphpad Prism version 7 (GraphPad Software, Inc. La Jolla, CA, USA). The primary objectives of the study were to compare the time to reach maintenance, the cumulative OIT dose taken during accumulation, and the number of moderate and severe adverse events among the three groups: PPOIT-001 active, PPOIT-001 placebo, and PPOIT-002. As an extension of these objectives, the percentage of time over the optimal protocol schedule, the number and percentage of delayed accumulation visits, and the total number of delayed days were also compared. In the analysis of the time to reach maintenance and the number of delayed days, only participants who reached maintenance were included because dropouts did not have complete data for these variables. In the comparison of adverse events, all participants were included, regardless of when or if they withdrew from the study. For each comparison, three Mann-Whitney U tests were performed: PPOIT-001 active vs. PPOIT-001 placebo, PPOIT-001 active vs. PPOIT-002, and PPOIT-001 placebo vs. PPOIT-002. The Mann-Whitney U test was chosen because the data were not normally distributed.

[0207] During group comparisons, adjustment was made for four possible confounding factors: age, sex, asthma diagnosis, and SPT wheal diameter. Subgroups are shown in Table 6. Comparisons across all three groups were performed with the Kruskal-Wallis H test, and comparisons between two groups were performed with the Mann-Whitney U test.

[0208] Univariate and multivariate regression analyses were performed to examine the correlation between accumulation duration and SU.

[0209] ethics PPOIT-001 and PPOIT-002 were approved by the Royal Children's Hospital Human Ethics Research Committee (HREC).

[0210] result In PPOIT-001, 62 children were randomized to receive active peanut OIT plus probiotic L. rhamnosus (N=31) or placebo plus placebo (N=31). In PPOIT-002, 20 children were assigned to receive active peanut OIT plus probiotic L. rhamnosus with a shortened accumulation phase. Baseline demographics for the three groups are shown in Table 6. Baseline demographics between groups were similar except for asthma, age, sex, and SPT wheal diameter. Based on these demographics, all three groups were divided into subgroups to determine whether important differences existed between these subgroups (see Table 7). No significant differences were observed between the subgroups.

[0211] [Table 6]

[0212] [Table 7]

[0213] In the PPOIT-001 active group, one child withdrew during the accumulation phase due to periodic abdominal pain after taking the dose. In the PPOIT-001 placebo group, two children withdrew: one because the family could not be involved in the study protocol and one because the mother was concerned about the child's safety or well-being after an SAE. In the PPOIT-002 group, two children withdrew: one because the child did not want to continue taking the dose and one because the child had dose-related recurrent abdominal pain after a dose increase to the 100 mg / day dose.

[0214] The time to achieve maintenance was shorter in subjects treated with PPOIT-002 As shown in Figure 1A and Table 8, the median time to maintenance was 38.4 weeks (IQR, 34.3-46.4) for PPOIT-001 active, 36.0 weeks (IQR, 33.4-37.8) for PPOIT-001 placebo, and 18.0 weeks (IQR, 16.0-20.0) for PPOIT-002. Significant differences were observed among all three groups: PPOIT-001 active vs. PPOIT-001 placebo (P = 0.03), PPOIT-001 active vs. PPOIT-002 (P < 0.0001), and PPOIT-001 placebo vs. PPOIT-002 (P < 0.0001).

[0215] As shown in Figure 1B and Table 8, the median percentage of participants exceeding the optimal time to maintenance (32 weeks for PPOIT-001 and 16 weeks for PPOIT-002) was 20% (IQR, 7-45%) for PPOIT-001 active, 13% (IQR, 4-18%) for PPOIT-001 placebo, and 13% (IQR, 0-25%) for PPOIT-002. A significant difference was observed between PPOIT-001 active and PPOIT-001 placebo (P=0.03), while the values ​​for the other comparisons, i.e., PPOIT-001 active vs. PPOIT-002 (P=0.18) and PPOIT-001 placebo vs. PPOIT-002 (P=0.82), were not significant.

[0216] PPOIT-002 was associated with fewer delayed accumulation visits and fewer delayed dose escalation days The median number of delayed accumulation visits attributable to all reasons (including response to treatment and rational reasons) was 5 (IQR, 3-7) for PPOIT-001 active, 4 (IQR, 3-6) for PPOIT-001 placebo, and 1 (IQR, 0-2) for PPOIT-002. There were significant differences between PPOIT-001 active and PPOIT-002 (P<0.0001) and between PPOIT-001 placebo and PPOIT-002 (P<0.0001).

[0217] For PPOIT-002, the median number of accumulation phase visits delayed due to treatment-related responses was 0 (IQR, 0-1). The median percentage of accumulation phase visits delayed due to treatment was 0% (IQR, 0-13%).

[0218] The median percentage of delayed accumulation visits was 31% (IQR, 19-44%) for PPOIT-001 active, 25% (IQR, 19-38%) for PPOIT-001 placebo, and 13% (IQR, 0-22%) for PPOIT-002. There were significant differences between PPOIT-001 active and PPOIT-002 (P<0.0001) and between PPOIT-001 placebo and PPOIT-002 (P=0.002).

[0219] The median total number of days participants exceeded their dosing protocol (e.g., remained on a dose longer than 14 days) was 48 days (IQR, 18.5-87) for PPOIT-001 active, 29 days (IQR, 13-50) for PPOIT-001 placebo, and 14 days (IQR, 0-19.5) for PPOIT-002. Significant differences were observed among all three groups: PPOIT-001 active vs. PPOIT-001 placebo (P=0.04), PPOIT-001 active vs. PPOIT-002 (P<0.0001), and PPOIT-001 placebo vs. PPOIT-002 (P=0.001).

[0220] The results are summarized in Figures 2A, 2B and 2C and percentage calculations are presented in Table 8.

[0221] Cumulative dose taken during accumulation The median cumulative dose taken during the accumulation phase was 108.50 g (IQR, 95.44-126.20) for PPOIT-001 active, 97.49 g (IQR, 92.64-108.60) for PPOIT-001 placebo, and 61.31 g (IQR, 59.40-62.34) for PPOIT-002. Significant differences were observed among all three groups: PPOIT-001 active vs. PPOIT-001 placebo (P = 0.02), PPOIT-001 active vs. PPOIT-002 (P < 0.0001), and PPOIT-001 placebo vs. PPOIT-002 (P < 0.0001).

[0222] The average median dose taken per week during the accumulation phase was 2.77 g (IQR, 2.46-3.12) for PPOIT-001 active, 2.89 g (IQR, 2.65-2.96) for PPOIT-001 placebo, and 3.45 g (IQR, 3.11-3.65) for PPOIT-002. Significant differences were observed between PPOIT-001 active vs. PPOIT-002 (P<0.0001) and between PPOIT-001 placebo vs. PPOIT-002 (P<0.0001).

[0223] The results are summarized in Figures 3A and 3B and Table 8.

[0224] PPOIT-002 had fewer moderate or severe AEs compared with PPOIT-001 during the accumulation phase Data on moderate and severe AEs during the accumulation phase were available for both PPOIT-001 and PPOIT-002 and were compared. AEs judged unlikely or unrelated to the study product were excluded. As shown in Figure 4 and Table 9, at least one moderate or severe AE was reported in 35.5% of children in the PPOIT-001 active group, 19.4% in the PPOIT-001 placebo group, and 25.0% in the PPOIT-002 group. The total number of moderate and severe AEs was 20 in the PPOIT-001 active group, 12 in the PPOIT-001 placebo group, and 6 in the PPOIT-002 group. The number of moderate and severe AEs per participant did not differ significantly by group, with a median of 1.5 (IQR, 0-1) in the PPOIT-001 active group, 0 (IQR, 0-0) in the PPOIT-001 placebo group, and 0 (IQR, 0-0.75) in the PPOIT-002 group. Overall, during accrual, 0.23% (20 / 8577) of doses in the PPOIT-001 active group, 0.16% (12 / 7364) of doses in the PPOIT-001 placebo group, and 0.24% (6 / 2449) of doses in the PPOIT-002 group resulted in moderate or severe reactions.

[0225] During the accumulation phase, one SAE related to the study product was recorded in the PPOIT-001 placebo group, as well as episodes of severe abdominal pain and throat tightness. No SAEs were observed in the active PPOIT-001 or PPOIT-002 groups during the accumulation phase.

[0226] In the PPOIT-002 group, three of the moderate and severe AEs during the accumulation period occurred on the accumulation day and three occurred during home administration. All of the moderate and severe AEs in the PPOIT-002 group occurred during the first 3 weeks of the accumulation period (data not shown).

[0227] Table 10 shows the frequency of AEs in PPOIT-001 and PPOIT-002, and Table 11 shows the time it took each subject to reach each dose under the PPOIT-002 schedule.

[0228] [Table 8]

[0229] [Table 9]

[0230] [Table 10]

[0231] [Table 11]

[0232] [Table 12]

[0233] Potential to achieve sustained unresponsiveness at the end of treatment After 18 months of treatment with both PPOIT001 and PPOIT002, the presence of persistent unresponsiveness (SU) was tested by double-blind, placebo-controlled peanut challenge.

[0234] Using pooled data from the PPOIT-001 active group and POIT-002, a univariate regression analysis was performed to determine whether the duration of the accumulation phase was associated with the likelihood of achieving sustained unresponsiveness at the end of treatment. We found that a shorter accumulation phase was associated with a significantly increased likelihood of achieving sustained unresponsiveness. Specifically, for every week of the longer accumulation phase, the likelihood, or more specifically, odds, of a subject achieving sustained unresponsiveness was 7.5% (1-0.925) lower (p=0.026) (see Table 12). Furthermore, the median duration of the accumulation phase was shortened by 11 weeks in subjects who achieved sustained unresponsiveness compared with those who did not. In contrast, the total cumulative dose of peanut protein received during OIT and the dose reached on the bolus day were not associated with the likelihood or odds of achieving sustained unresponsiveness. Univariate regression analysis further indicated that asthma at study entry and allergic rhinitis at study entry influenced the likelihood or odds of achieving SU. Therefore, a logistic regression model was performed to estimate the effects of asthma, allergic rhinitis, and accumulation duration on SU. This showed that accumulation duration remained a significant predictor of SU. Specifically, in this model, which included both baseline asthma and allergic rhinitis, the likelihood or odds of achieving SU increased by 1.1-fold for each 1-week decrease in accumulation duration.

[0235] [Table 13]

[0236] Consideration The objective of this study was to compare the time to maintenance dose in PPOIT-001 (32 weeks) with that of PPOIT-002 (16 weeks). Specifically, the time to maintenance, the delay in planned accumulation, the cumulative dose taken during the burst and accumulation phases, and the number of adverse events were compared. The study found that the accumulation phase of the PPOIT-002 group was either equivalent to or superior to both the PPOIT-001 active and PPOIT-001 placebo accumulation phases in terms of acceptability and frequency of adverse events.

[0237] The time to maintenance was significantly shorter in the PPOIT-002 group. This is to be expected since the schedule was half as long as PPOIT-001. Furthermore, the PPOIT-002 accumulation schedule, despite being shorter, was well tolerated. Because the new accumulation schedule was not well tolerated, the delay due to response brought the PPOIT-002 group (18 weeks) closer to the PPOIT-001 active (38 weeks) and PPOIT-001 placebo (36 weeks) groups, thereby bringing the median time to maintenance. When adjusting for the different accumulation schedules by focusing solely on the median percentage of time participants exceeded the optimal time to maintenance, it can be further observed that PPOIT-002 (13% exceeding optimal time) was equal to the PPOIT-001 placebo group (13%) and superior to the PPOIT-001 active group (20%).

[0238] When comparing protocol deviations in the form of delayed accumulation-phase visits and number of delayed days, Figure 2 shows that the PPOIT-002 group deviated significantly less from the accumulation protocol than both the PPOIT-001 active and PPOIT-001 placebo groups. Focusing exclusively on the PPOIT-002 group, it is clear that the median number of delayed accumulation-phase visits due to treatment-related reactions was 0, meaning that the majority of accumulation-phase visits were delayed for rational reasons (e.g., public holidays, family members unable to attend, study team inability to accommodate scheduled visits), and the more rapid dose escalation protocol of PPOIT-002 was not associated with an increased number of adverse reactions resulting in delayed accumulation-phase visits. A longer accumulation phase theoretically corresponds to more accumulation-phase visits, where the reason for the delay could be rational, and one reason could be that PPOIT-001 participants had twice as many accumulation-phase visits to attend, resulting in more protocol deviations. The very low number of accumulation phase visits in PPOIT-002 that were delayed due to treatment indicates that accumulation was well tolerated and did not often result in complications in the form of protocol deviations and reactions that mandated delays.

[0239] Although the number of AEs was lower in the PPOIT-002 group compared with the PPOIT-001 active group, there were an overall very low number of AEs: 20 (0.21% of the given dose) in the PPOIT-001 active group, 12 (0.16% of the given dose) in the PPOIT-001 placebo group, and 6 (0.24% of the given dose) in the PPOIT-002 group. At a minimum, PPOIT-002 was non-inferior to PPOIT-001 in terms of safety and tolerability, despite incorporating a more rapid dose escalation regimen.

[0240] The cumulative dose taken during the accumulation phase is inherently lower in PPOIT-002 because the accumulation phase lasted half the time the subjects spent in PPOIT-001. Looking at the average dose taken each week, it is higher in PPOIT-002 because the dose escalation was steeper, with a two-fold increase in dose to the 800 mg dose. Calculating the optimal dose taken over the entire course of treatment (assuming participants followed the dosing protocol and never missed a dose) yields a total cumulative dose of 654 g for PPOIT-001 (32 weeks of accumulation and 40 weeks of maintenance) and 845 g for PPOIT-002 (16 weeks of accumulation and 56 weeks of maintenance).

[0241] The multidimensional approach provided herein provides a more comprehensive understanding of the tolerability and safety of the new dose escalation schedule in PPOIT-002 when compared to PPOIT-001. Using the time to reach maintenance, the tolerability of treatment can be assessed along with the percentage of time to optimum and the number of delayed accumulation visits. The poor tolerability of the new dose escalation schedule was attributed to a longer time to maintenance, a higher percentage of time to optimum, and more delayed accumulation visits.

[0242] When comparing moderate to severe AEs for PPOIT-001 and PPOIT-002, it was unexpectedly observed that PPOIT-002 had a substantially similar rate of moderate to severe AEs, despite the fact that the accumulation phase in PPOIT-002 was half as long. The rates of AEs from PPOIT-001 and PPOIT-002 are limited to the burst and accumulation phases of treatment and therefore may be lower than would be expected if they included AEs from the entire treatment period (i.e., the burst, accumulation, and maintenance phases). However, most peanut OIT studies that stratify the rate of AEs based on treatment phase have found that the majority of AEs occur near the beginning of treatment between the burst and accumulation phases, making it unlikely that the rate of AEs would be significantly higher than shown here.

[0243] Compared to many of these trials, the reporting of AEs in PPOIT-002 and PPOIT-001 is robust and provides an accurate picture of AEs that occurred during the trials based on the CoFAR severity rating scale.

[0244] Previous peanut OIT schedules have employed dose escalation to avoid AEs, as the greatest response occurs during the accumulation phase, especially on the day the dose is increased. Therefore, prior art approaches have minimized the rate of AEs during dose escalation by shifting to a slower dosing schedule. For example, a recent large-scale multicenter study of 300 mg OIT employed a 26-week accumulation phase to reach 300 mg (PALISADE study - Vickery 2018 NEJM, supra). The improved safety profile of PPOIT-002 is likely attributable to the more rapid accumulation schedule of peanut OIT, as this was limited by the altered administration parameters. While live bacteria may have enabled the successful application of a more rapid accumulation schedule, it is clear that the only change between PPOIT-001 and PPOIT-002 was the more rapid accumulation schedule (completed in half the time compared to the PPOIT-001 schedule). For peanut OIT to be implemented in a clinical setting, it must be practical. A long build-up phase, when participants need to visit the clinic every two weeks for dose escalation, requires both family and resource augmentation, as a physician and nurse must be present at each visit. A shorter build-up with steeper dose escalation would mean fewer visits and fewer resources, but to date has not proven feasible due to higher rates of AEs and poorer tolerability. However, the findings in this study suggest that a more rapid build-up schedule may be possible without compromising safety. Furthermore, a shorter build-up was unexpectedly associated with an increased likelihood or odds of achieving sustained unresponsiveness. The comparison between PPOIT-001 and PPOIT-002 in our study, where the only change was the dose escalation schedule, suggests that a shorter dose escalation schedule may be possible to treat peanut allergy without reducing tolerability or compromising safety.

[0245] Example 2: Measurement of pDC induction by live bacteria This example reports the results of experiments in which the effect of live bacteria on the number of circulating plasmacytoid dendritic cells (pDCs) was examined after two weeks of oral administration of live bacteria in healthy adults with or without allergic disease.

[0246] Materials and Methods Administration of live bacteria One hundred twenty healthy adults were recruited. Six different commercially available live bacteria were tested (Table 13). Each live bacteria was administered daily at a standard dose to 20 healthy adults for two weeks. Participants were assigned in order to receive one of the six live bacteria. Subjects were considered "healthy" if they had no serious illnesses, were generally healthy, and were not receiving immunomodulatory therapy. The presence of allergic disease was not an exclusion criterion, as 40% to 50% of the Australian population is affected by one or more allergic conditions (asthma, allergic rhinitis, eczema, food allergies). To determine whether the effects of the live bacteria were similar in adults with and without allergic disease, subjects were subdivided into those with and without allergic disease. Details of allergic diseases observed in healthy adults are shown in Table 14.

[0247] [Table 14]

[0248] [Table 15]

[0249] Blood collection Twenty-mL blood samples were collected before (day 0) and 14 days after (day 14) live bacterial challenge. Blood samples were processed by density gradient centrifugation within 2 hours of collection and separated into plasma and peripheral blood mononuclear cells (PBMCs). PBMCs were cryopreserved and stored under liquid nitrogen for later batch analysis.

[0250] Cell culture for 48 hours PBMCs were thawed using a ThawSTAR Automated Cell Thawing System (MedCision, San Rafael, CA). Upon thawing, cells were added dropwise to 10 ml of chilled RPMI (Gibco Life Technologies, Grand Island, NY) with 2% fetal bovine serum (FBS) and spun at 400 g for 5 minutes. The supernatant was removed, and cells were resuspended in 1 ml of 2% FBS in RPMI in preparation for counting. Cell numbers were determined by trypan blue exclusion using a TC20 automated cell counter (Biorad, Hercules, CA).

[0251] 4×10 -5 PBMC cultures were set up in round-bottom 96-well plates with 200,000 cells / well in AIM-V serum-free medium (Gibco Life Technologies, Grand Island, NY) with M 2-mercaptoethanol in the presence or absence of antigen (heat-killed live bacteria or medium alone) and incubated at 37°C under 5% CO for 48 hours.

[0252] Flow cytometry analysis of pDCs Prior to analysis, the plate was spun at 400g at 4°C. The supernatant was removed and placed in another 96-well plate, frozen at -80°C, and prepared for further analysis. Cells were maintained in the wells in which they were cultured. 200 μl of PBS was added to each well, and the plate was spun at 400g at 4°C. The plate was tapped to sink, and the PBS wash was removed. 100 μL of Fixable Viability Dye 510 (BD Biosciences, San Jose, CA) prepared at 0.5 μl / ml in PBS was added to each well, mixed thoroughly, and incubated for 15 minutes at room temperature (RT) and light-protected. 100 μL of FACS buffer (2% FBS in PBS) was added to each well, and the plate was spun at 400g at 4°C and tapped. Antibody cocktails consisting of anti-human HLA DR BB515, CD123 PerCPy5.5, CD11c PE-Cy7, CD1c-PE, series (CD3, CD19, CD20 APC-H7, and CD56) APC-Cy7, CD14 V450, and CD16 BUV395 (all antibodies purchased from BD Biosciences, San Jose, CA, except for CD123 and CD56, which were purchased from Biolegend, San Diego, CA) were added to each well in 40 μl of FACS buffer at the indicated titers (Table 15), mixed thoroughly, and incubated on ice for 20 minutes. Unbound antibodies were thoroughly washed with 200 μl of FACS buffer, the plate was spun and tapped, and then 150 μl of FACS buffer was added to each well and prepared for analysis on a Fortessa X-20 high-throughput system (BD Biosciences, San Jose, CA). Compensation controls for each fluorophore were prepared with anti-mouse Ig CompBeads (BD Biosciences, San Jose, CA), and compensation was performed using BD FACSDIVA software (BD Biosciences, San Jose, CA). Approximately 200,000 events were collected per well.

[0253] [Table 16]

[0254] Post-acquisition analysis Post-acquisition analysis was performed using FlowJo v10.3 (FlowJo, LLC, Ashland, OR). pDCs were identified as HLA-DR+ lineage-(CD3, CD19, CD20, CD56)CD14-CD16-CD11c-CD123+ cells. The number of pDCs in HK probiotic-stimulated cultures was calculated by subtracting the percentage of pDCs in unstimulated cultures from the percentage of pDCs in HK probiotic-stimulated cultures, adjusting for nonspecific variations in baseline pDC numbers between subjects across different time points.

[0255] statistical analysis Data are presented as median and interquartile range at each time point.

[0256] result Effect of live bacterial supplementation in vivo on the proportion of pDCs in peripheral blood The median percentage of pDCs in PBMC cultures from healthy adults increased on day 14 (14 days post-treatment) compared to day 0 in all live bacteria groups (Table 16). The percentage of pDCs increased two-fold from day 1 to day 14 for LGG (8.49% to 17.56%), B. lactis (increased from 6.31% to 11.54%), S. boulardii (1.85% to 3.12%), and E. coli Nissle 1917 (3.76% to 7.21%), and four-fold from day 1 to day 14 for S. thermophilus (0.45% to 1.91%) and B. breve (0.61% to 2.45%).

[0257] Next, we examined the effect of live bacteria on the proportion of pDCs in the presence or absence of allergic disease to determine whether the effects of live bacteria were similar in healthy adults with and without allergic disease. On both day 0 (before live bacteria treatment) and day 14 (after live bacteria treatment), the proportion of pDCs in adults with and without allergic disease was similar (not significantly different, p>0.05), indicating that the induction of pDCs by live bacteria is not altered by the presence of allergic disease (Figure 5).

[0258] [Table 17]

[0259] These data show that oral administration of six different live bacteria from different genera to healthy adults for 14 days resulted in a detectable increase in the proportion of pDCs (pDCs) throughout the body. The effect of oral live bacteria administration on pDC response capacity was assessed by measuring the number of pDCs generated in vitro (in HK probiotic-stimulated cultures to mimic in vivo exposure) before and after oral administration of live bacteria. The data show that pDC generation increased after 14 days of live bacteria supplementation compared to day 0. The increase in pDC numbers after 14 days of oral administration of live bacteria is consistent with an enhanced ability to induce antigen-specific Tregs and subsequently inhibit allergic responses (Colonna et al., Nat Immunol 5:1219-1226, 2004; Akdis and Akdis, WAO J. 8:17, 2015). Present pDCs mediated antigen encounters with antigen-specific naive T cells, leading to their differentiation into regulatory T cells (Tregs). The effect of live bacteria on pDCs was similar in adults with and without allergic disease (Fig. 5).

[0260] Example 3 - Comparison of PPOIT-003 Data with Prior Art PPOIT-003 was a three-arm, multicenter, randomized, controlled clinical trial conducted using the same cumulative protocol as PPOIT-002. Subjects were randomized to receive one of three interventions: placebo, peanut OIT with live bacteria, or peanut OIT without live bacteria. Treatment lasted 18 months, after which patients were tested for both desensitization and persistent unresponsiveness (SU) using the same food challenge as used in PPOIT-2.

[0261] Comparison of the percentage of SU achieved following peanut OIT using a shorter accumulation regimen (without live bacteria) with prior art (Vickery 2014 supra) A randomized trial (PPOIT-003) comparing live peanut OIT versus peanut OIT alone versus placebo was conducted. OIT alone induced SU in 50.6% of subjects compared with 5.1% of placebo-treated subjects. This rate of SU with peanut OIT is higher than that reported when OIT was administered using a longer duration in a similar population of subjects with similar age and peanut SPT wheal diameter (Table 17). This suggests that peanut OIT administered using a shorter duration caused a higher rate of SU compared with peanut OIT administered using a longer duration. Furthermore, prior trials of peanut OIT using a longer duration also used higher maintenance doses and shorter periods of allergen abstinence (both of which are thought to increase the possibility or odds of achieving SU) before testing for SU.

[0262] [Table 18]

[0263] Previous studies have suggested that longer total treatment durations and higher maintenance OIT doses allow for an increase in the rate of sustained unresponsiveness (SU). Therefore, the shorter total treatment duration and lower maintenance dose were surprising, but the higher rate of SU was demonstrated with peanut OIT in the PPOIT-003 study in a group of patients of similar age. This unexpected result is due to the more rapid initial dosing, achieving 2000 mg within just 16 weeks.

[0264] Safety and Tolerability of Peanut OIT Using a Shorter Storage Period Compared to Prior Art

[0265] [Table 19]

[0266] The significantly increased dosing schedule of peanut OIT in PPOIT-003 (reaching 2000 mg within 16 weeks compared to 300 mg within 24 weeks in PALISADE) would be expected to result in an increased number of adverse events. We compare TEAEs (SOC and PT) including gastrointestinal, respiratory, and skin, as well as total SAEs, overall withdrawal rates, and the proportion of subjects reporting withdrawal due to AEs. It is surprising that these events are not increased, even in the absence of live bacteria.

[0267] Exposure-adjusted incidence rates of AEs can also be used to compare the safety of accelerated schedules with more gradual schedules. The exposure-adjusted incidence rate of AEs is calculated by dividing the number of AEs by the actual number of years of treatment, allowing for direct comparison of treatments when differences in duration of treatment are observed. Table 19 compares the exposure-adjusted incidence rates of AEs reported with peanut OIT (2000 mg maintenance dose) administered using a shorter duration (in the PPOIT-003 study) with peanut OIT administered using a longer, lower 300 mg maintenance dose (in the PALISADE study). The exposure-adjusted incidence rate of AEs is approximately four-fold lower with the more rapid schedule, despite reaching a six- to seven-fold higher maintenance dose.

[0268] [Table 20]

[0269] Comparison of the effects of including live bacteria on safety signals In the PPOIT003 trial, a direct comparison of the effect of adding live bacteria to peanut OIT can be made by comparing subjects receiving live bacteria-peanut OIT with subjects receiving peanut OIT alone. The rate of withdrawal, dose adjustments during the accumulation phase, proportion of subjects reporting AEs, and exposure-adjusted incidence of AEs can provide information about the tolerability and safety of the treatment schedule.

[0270] All oral immunotherapy protocols allow for dose adjustment if a child has a severe reaction to the given dose. In these situations, the dose is reduced over a period of time. As a result, the number of dose adjustments that occur during the titration phase provides an indication of how well-tolerated the treatment is within that cohort.

[0271] [Table 21]

[0272] The number of withdrawals from the study and the number of withdrawals from treatment provide an indication of the tolerability of the treatment. In the PPOIT-003 study, subjects receiving live bacteria in combination with OIT had reduced withdrawals compared to subjects receiving OIT alone (Table 21).

[0273] [Table 22]

[0274] Effects on children aged 1 to 5 years The beneficial effect of live bacteria was particularly evident in children between 1 and 5 years of age, as shown in Tables 22 and 23, which show a comparison of withdrawal rates and adverse events in the 1-5 age group in subjects treated with live bacteria plus OIT (PPOIT) and OIT alone. The results indicate that live bacteria improve the tolerability of peanut OIT treatment (reduced withdrawal) in this young age group, likely due to a protective effect against systemic and gastrointestinal side effects.

[0275] [Table 23]

[0276] [Table 24]

[0277] Example 4 - Effect of PPOIT and OIT on peanut sIgE levels Peanut sIgE is involved in the presence of allergy to peanuts and initiates a cascade of immune changes that lead to the symptoms of an allergic reaction. Peanut sIgE provides a biomarker for clinical peanut allergy. The absence of peanut sIgE, or a negative test result of peanut sIgE <0.35 kU / L, is a highly specific marker for the absence of IgE-mediated allergy to peanuts. Conversely, the presence of peanut sIgE by itself does not necessarily result in clinical peanut allergy, but increasing levels of peanut sIgE increase the likelihood of clinical allergy.

[0278] In the randomized trial of PPOIT-003 described in Example 3, serum levels of peanut sIgE were measured by ImmunoCap (Phadia) at baseline (T0), end of treatment (T1), 8 weeks after treatment (T2), and 12 months after treatment (T3). At baseline, sIgE levels were similar across the three treatment groups. Results are shown in Table 24, and groups were compared in a pairwise fashion using the Wilcoxon rank sum test.

[0279] At T1, peanut sIgE levels were significantly lower in the PPOIT group (6.6 kU / L) compared with the placebo group (14.5 kU / L) (p=0.0460) and in the OIT group (3.2 kU / L) compared with the placebo group (14.5 kU / L) (p=0.0057), but were not significantly different between the PPOIT and OIT groups (6.6 kU / L and 3.2 kU / L, respectively, p=0.2484).

[0280] At T2, peanut sIgE levels further decreased in both the PPOIT (3.7 kU / L) and OIT (2.7 kU / L) groups and remained significantly lower than the placebo group (18.0 kU / L) (p=0.009 and p=0.001, respectively). No significant difference in peanut sIgE levels was observed between the PPOIT and OIT groups (p=0.3700).

[0281] The median change from baseline in peanut sIgE at T1 was significantly greater in the PPOIT group (-5.0 kU / L) and the OIT group (-2.2 kU / L) than in the placebo group (0.3 kU / L) (p<0.0001 and p=0.0005, respectively). There was no significant difference in the median change from baseline in peanut sIgE at T1 between PPOIT and OIT (p=0.2507). At T2, the median change from baseline in peanut sIgE remained significantly greater in the PPOIT group (-2.7 kU / L) and the OIT group compared with the placebo group (2.4 kU / L) (both p<0.0001). There was no significant difference in the median change from baseline in peanut sIgE between the PPOIT and OIT groups (p=0.6331).

[0282] These results indicate that treatment with both PPOIT and OIT modulated the underlying peanut-specific allergic immune response. Other studies of peanut OIT have not shown a significant reduction in peanut sIgE after 1 to 2 years of treatment, although reductions are usually achieved only after 4 or more years of treatment.

[0283] [Table 25]

[0284] [Table 26]

[0285] References Wood, JACI; vol. 27(3): 151-159, 2017. Vickery et al., JACI; 133(2): 468-75, 2014. PALISADE Study led by Vickery, N Engl. J Med. 2018 Nov 22;379(21):1991-2001. Share 10,265,349 likes Tang et al., J Allergy Clin Immunol 135(3): 737-744, 2015. Colonna et al, Nat Immunol 5:1219-1226, 2004. Akdis and Akdis, WAO J.8:17, 2015. Macginnitie et al., (2017) J Allergy Clin Immunol. 139:873–81. Anagnostou et al.,(2014) Lancet; 383:1297–304. Schneider et al., (2013) J. Allergy Clin Immunol.132: 1368-74.

Claims

1. 1. A therapeutic agent comprising a peanut allergen for use in a method for treating peanut allergy in a subject, the method comprising administering the peanut allergen to the subject by an oral immunotherapy regimen comprising a dose escalation phase comprising a ramp-up phase and a build-up phase, wherein the peanut allergen is administered in doses escalating from an initial dose of the allergen equivalent to up to 5 mg of peanut protein or an initial dose of the allergen equivalent to up to 2 mg of peanut protein within 4 to 9 weeks from administration of the initial dose to a dose of the allergen equivalent to at least 200 mg of peanut protein; The peanut protein is the total protein content of peanuts, the subject has not received anti-IgE antibodies prior to initiation of an oral immunotherapy (OIT) regimen or during the dose escalation phase; during the rapid phase, escalating doses are administered from the initial dose to a dose of the allergen equivalent to at least 12 mg of peanut protein within 1 to 12 hours of administration of the initial dose; Treatment drug.

2. During the dose escalation phase, the peanut allergen dose is: (i) a dose of the allergen equivalent to at least 400 mg of peanut protein within 6 to 11 weeks of administration of the initial dose; and / or (ii) a dose of the allergen equivalent to at least 800 mg of peanut protein within 8 to 13 weeks of administration of the initial dose; and / or (iii) a dose of the allergen equivalent to at least 2 g of peanut protein within 16 to 24 weeks of administration of the initial dose. The therapeutic agent of claim 1 , wherein the

3. 3. The method of claim 1 or claim 2, wherein the dose escalation phase comprises a series of approximately doubling dose increases from the initial dose to the dose of at least 200 mg, 400 mg, 800 mg, or 2 g.

4. The method of any one of claims 1 to 3, wherein the dose escalation period is 8 to 24 weeks, and the final dose is reached at the end of the dose escalation period.

5. 5. The therapeutic agent of claim 1, wherein a final dose is reached at the end of the dose escalation phase, and the oral immunotherapy regimen further comprises a maintenance phase after completion of the dose escalation phase, wherein in the maintenance phase, the peanut allergen is administered at a set maintenance dose that is ±10% of the final dose reached at the end of the dose escalation phase.

6. (i) the maintenance dose is at least 200 mg, 300 mg, 400 mg, 500 mg, 600 mg, 700 mg, 800 mg, 900 mg, 1000 mg, 1100 mg, 1200 mg, 1300 mg, 1400 mg, 1500 mg, 1600 mg, 1700 mg, 1800 mg, 1900 mg, 2000 mg, 2100 mg, 2200 mg, 2300 mg, 2400 mg, 2500 mg, 2600 mg, 2700 mg, 2800 mg, 2900 mg, 3000 mg, 3100 mg, 3200 mg, 3300 mg, 3400 mg, 3500 mg, 3600 mg, 3700 mg, 3800 mg, 3900 mg, 4000 mg, 4100 mg, 4200 mg, 4300 mg, 4400 mg, 4500 mg, 4600 mg, 4700 mg, 4800 mg, 4900 mg, 5000 mg, 5100 mg, 5200 mg, 5300 mg, 5400 mg, 5500 mg, 5600 mg, 5700 mg, 5800 mg, 5900 mg, 6000 mg, 6100 mg, 6200 mg, 6300 mg, 6400 mg, 6500 mg, 6600 mg, 6700 mg, 6800 mg, 6900 mg, 7000 mg, 7100 mg, 7200 mg, 7300 mg, 7400 mg and / or the allergen corresponds to about 0 mg, 2500 mg, 2600 mg, 2700 mg, 2800 mg, 2900 mg, 3000 mg, 3100 mg, 3200 mg, 3300 mg, 3400 mg, 3500 mg, 3600 mg, 3700 mg, 3800 mg, 3900 mg, 4000 mg, 4100 mg or about 4200 mg of peanut protein; and / or (ii) the duration of the maintenance phase is at least 2 weeks after the end of the dose-escalation phase, or the duration of the maintenance phase is 20 to 104 weeks; The therapeutic agent according to claim 5.

7. The method of any one of claims 1 to 6, wherein the peanut allergen dose is administered at least every 3 days, every 2 days, or daily during the accumulation phase.

8. (i) the peanut allergen is, is present in, or is derived from a peanut protein; and / or (ii) the peanut allergen is provided as peanut protein, or peanut flour or a defatted form thereof; and / or (iii) the peanut allergen is one or more of Ara h1, h2, h3, h6, h8, or h9, or a modified form of Ara h1, h2, h3, h6, h8, or h9; The therapeutic agent according to claim 7.

9. 9. The method of claim 8, wherein the peanut allergen is administered in or on applesauce, pudding, yogurt, or chocolate.

10. The therapeutic agent according to any one of claims 1 to 9, wherein the subject is under 18 years old, under 10 years old, under 5 years old, between 1 month and 12 years old, under 6 years old, between 6 and 12 years old, or between 1 and 5 years old.

11. The therapeutic agent of any one of claims 5 to 10, wherein reducing the duration of the dose escalation phase improves the likelihood or odds of the subject achieving sustained unresponsiveness compared to oral immunotherapy regimens using longer dose escalation phases to reach the same maintenance dose, or reaching the maintenance dose within 8 to 24 weeks improves the likelihood or odds of the subject achieving sustained unresponsiveness compared to oral immunotherapy regimens using longer dose escalation phases to reach the same maintenance dose.

12. The method of any one of claims 1 to 11, wherein the treatment further comprises orally administering live bacteria at least once during the rapid phase and at least once every week during the remainder of the dose-escalation phase.

13. The method of claim 12, wherein the live bacteria are administered at least every three days or daily.

14. Each dose of the live bacteria was 1 x 10 ８ cfu ~ 2 x 10 １０ The therapeutic agent according to claims 1 to 13, wherein the dose is cfu.

15. The therapeutic agent according to any one of claims 12 to 14, wherein the live bacteria are capable of inducing an increase in the number of tolerogenic dendritic cells after in vivo administration.

16. The therapeutic agent of claim 15 , wherein the tolerogenic dendritic cells are plasmacytoid dendritic cells (pDCs).

17. the live bacteria are of the species Lactobacillus, Bifidobacterium, Saccharomyces, Streptococcus, Escherichia or Bacillus, The therapeutic agent according to any one of claims 12 to 16.

18. i) the live bacteria are species of Lactobacillus selected from the list of Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus johnsonii, Lactobacillus lactis, Lactobacillus plantarum, Lactobacillus reuteri, Lactobacillus rhamnosus, Lactobacillus salivarius and Lactobacillus helveticus, or the live bacteria are species of Lactobacillus selected from the list of Lactobacillus acidophilus, Lactobacillus casei, Lactobacillus johnsonii, Lactobacillus lactis, Lactobacillus plantarum, Lactobacillus reuteri, Lactobacillus rhamnosus, Lactobacillus salivarius and Lactobacillus helveticus, or the live bacteria are species of Lactobacillus selected from the list of Lactobacillus rhamnosus, Lactobacillus salivarius and Lactobacillus helveticus, rhamnosus), or ii) the live bacteria is Lactobacillus rhamnosus GG, Bifidobacterium lactis, Saccharomyces boulardii, Escherichia coli Nissle 1917, Streptococcus thermophilus or Bifidobacterium breve; The therapeutic agent of claim 17.

19. The therapeutic agent according to any one of claims 12 to 18, wherein in each administration of the peanut allergen, the live bacteria and the peanut allergen are administered in a single or separate compositions, simultaneously, separately or sequentially, or in each administration of the peanut allergen, the peanut allergen is administered 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 10 minutes, 30 minutes, 1 hour, 2 hours or more, up to 12 hours, before the live bacteria, or the live bacteria is administered 1 minute, 2 minutes, 3 minutes, 4 minutes, 5 minutes, 10 minutes, 30 minutes, 1 hour, 2 hours or more, up to 12 hours, before the peanut allergen.

20. 20. The therapeutic agent according to any one of claims 12 to 19, wherein in each administration of the peanut allergen, the peanut allergen and the live bacteria are administered separately at intervals of up to 7 days, or at intervals of up to 1 day, 2 days, 3 days, 4 days, 5 days, or 6 days.

21. The method of any one of claims 12 to 20, wherein the live bacteria are administered in water, cow's milk, soy milk, or other milk or drink.

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