Peanut Oral Immunotherapy Value Assessed In Children

Key Takeaways

• This economic evaluation compared probiotic and peanut oral immunotherapy (PPOIT), peanut oral immunotherapy (OIT), and no treatment for children with peanut allergy.
• Both PPOIT and OIT were cost-effective compared with no treatment when remission was the effectiveness outcome.
• When effectiveness was assessed using quality-adjusted life years (QALYs), PPOIT offered the best value.

Rather than focusing on clinical efficacy alone, the study examined whether the benefits of these therapies outweighed their costs and adverse effects over time. The analysis was performed alongside a multicenter randomized, placebo-controlled clinical trial in Australia and framed treatment decisions through a cost-effectiveness lens.

The study included 201 children aged 1 to 10 years, with 79 assigned to PPOIT, 83 to OIT, and 39 to placebo, which informed the hypothetical no-treatment comparison. The economic model used a 10-year time horizon, consisting of 1.5 years of active treatment, 2 years of posttreatment follow-up, and 6.5 years of extrapolation. Costs were assessed from a health care payer perspective and included treatment delivery and adverse event costs.

Effectiveness was evaluated using 2 distinct outcomes: remission achieved and QALYs gained. This distinction mattered because the relative value of PPOIT and OIT depended on which outcome was prioritized. The investigators therefore presented cost-effectiveness results not as a single verdict, but as a comparison that shifted according to the measure of benefit.

Over the 10-year horizon, the estimated mean cost per patient was A$3956 for PPOIT, A$3582 for OIT, and A$249 for no treatment. Annual remission was substantially higher with active treatment: 34.1% for PPOIT, 35.1% for OIT, and 7.3% for no treatment. In the modeled comparison, total QALYs gained were 0.096 for PPOIT, 0.055 for OIT, and 0 for no treatment, reflecting assumptions applied to the hypothetical no-treatment scenario rather than directly observed trial outcomes. PPOIT was slightly more costly than OIT and achieved similar remission rates, with OIT showing a marginally higher rate that was not clinically meaningful, while PPOIT was associated with higher modeled quality-of-life.

Compared with no treatment, both active strategies were cost-effective when remission was the effectiveness outcome. PPOIT was associated with A$1384 per year of remission achieved (95% CI, A$1269–A$1415), and OIT with A$1199 per year of remission achieved (95% CI, A$1091–A$1217). These results supported the conclusion that both PPOIT and OIT represented good value relative to no treatment for achieving remission.

When effectiveness was assessed using QALYs, PPOIT offered the best value. Compared with no treatment, PPOIT was associated with A$38,435 per QALY gained (95% CI, A$31,058–A$48,668), whereas OIT was associated with A$60,840 per QALY gained (95% CI, A$49,479–A$86,531). In the direct comparison between PPOIT and OIT, PPOIT yielded better quality-of-life at a cost of A$8985 per additional QALY gained, which the authors interpreted as well below commonly referenced willingness-to-pay thresholds.

The authors noted that OIT was technically less costly and slightly more effective than PPOIT for remission, but the difference was very small and not considered practically meaningful. By contrast, PPOIT showed an advantage when QALYs were prioritized, likely reflecting differences in quality-of-life and adverse event profiles. The study therefore emphasized that the cost-effectiveness conclusion depends on which outcome matters most: remission alone or broader quality-of-life.

Sensitivity analyses showed that cost-effectiveness was strongly influenced by treatment product pricing and patient quality-of-life assumptions. When a higher OIT product price based on the NICE-listed Palforzia cost was applied, both active treatments became substantially more expensive and were no longer cost-effective for QALY gains compared with no treatment. This reinforced the authors’ view that pricing is a key determinant of treatment value.

Overall, the authors concluded that PPOIT and OIT are both good-value options compared with no treatment for remission outcomes, while PPOIT offers better value when QALYs are prioritized. They framed the findings as relevant to shared decision-making, since the preferred strategy may depend on whether families and clinicians place greater emphasis on remission or on quality-of-life.