Why I (still) perform oral immunotherapy to foods

You know what? I have been really pathetic with my blog. I just need to do it. Every week I need to try and crank something out. It's good to try and get my thoughts down on screen and get some feedback every now and then.

I've been asked to give an update on my oral immunotherapy (OIT) for food allergy program since beginning it towards the end of last year. OIT has changed my life, and I'm not even food allergic. It has become the single most rewarding part of my professional practice. It has also become the most time intensive part of my practice. The OIT program is mine, and mine alone. Because the parents and children in the OIT program put their faith in me and entrust me with so much, I basically do it all to ensure no errors are made. I'm available to them 24/7 by cell phone. I measure every bit of flour. I make the peanut solutions. I even make the labels on the bottles. I talk to the family and perform an exam prior to each up-dose.  As the program picks up steam, I probably will not able to keep up on all this and will eventually have to let go of some of my responsibilities.  I will not become less accessible, though.  That is the cornerstone of my OIT practice.  

But you know what? All of this extra work is worth it. These kids are amazing. These OIT families are amazing. The lengths that they will go, the commitments that they will make, to provide their child a life free of the anxiety that comes from being food allergic is inspiring to me as a parent.  The children's bravery at bucking the trend, at going along with something that their prior allergist might be against, is pretty awesome.  Here is a point of emphasis:  These kids are cool.  Really cool. 

I've also become much more adept at food challenges. Prior to my OIT life, the main reason to do a food challenge was to see if a child had outgrown their food allergy. Now, it is just as common for me to perform a food challenge to confirm the food allergy prior to undergoing such a time intensive process. As exciting as it is to see a food allergic kid progress through oral immunotherapy and tackle the food head on, it is just as exciting and rewarding to have a child pass a food challenge to something that they previously thought they were allergic to--and leave the clinic that day with complete and total freedom from that food's effect on their life. I have seen a kid with a peanut IgE of 12 and ara h2 IgE of 5 pass his challenge with flying colors.  I have also seen a kid with a walnut IgE of 0.6 fail a challenge on the first dose.

We have had minimal problems to date with the therapy, but the program is still in its infancy really. The most common side effects are some mild GI issues.  Probably the biggest one that I underestimated prior to starting this is the anxiety.  It is something that the kids, especially the older ones, can really struggle with.  The other thing I underestimated was how much peanut allergic kids seem not to like the taste of peanut (go figure).

My OIT practice is still small I think compared to most of the clinics around the country that are offering the therapy. I think I have around 15 patients right now. However, almost month-to-month, there is increased growth, excitement and interest in the program. Nearly every week now, I am either starting a patient on oral immunotherapy or performing a food challenge to see if a child would benefit from it.

OIT works. I don't think that any of the arguments that contend for more research prior to it being offered in practice, especially in regards to peanut, hold any water. Research should continue, don't get me wrong. Research on allergy shots for environmental allergies continues even while subcutaneous allergen immunotherapy is widely practiced in the community. The research is there to fine-tune the practice and answer questions as they arise. But fundamentally, I believe that oral immunotherapy to foods is safe and effective. 

I've always tended to believe that the most effective argument against oral immunotherapy was along the lines of the cold hard economics of it. The number of food allergic kids required to do food oral immunotherapy to prevent one food allergy related death is probably quite high (meaning the number needed to treat to prevent a death would maybe be too high to justify the price of the therapy, at least on a populational level). But, this economic argument that some allergists postulate no longer holds water either. Because a peanut flour pill has been fast tracked by the FDA. If one thought that the economics of OIT didn't make sense using run-of-the-mill peanut flour that can be bought anywhere, guess what will happen when we use "pharmaceutical grade" peanut flour that the patient is prescribed?  The cost of oral immunotherapy will be astronomical. Furthermore, when the peanut pill is eventually approved by the FDA, the same questions that hold many people back from offering OIT such as what's the most effective dosing protocol, desensitization versus tolerance induction, and side effects, will all still be out there. However, since the peanut flour will suddenly be "FDA-approved" using a more regimented protocol with likely less flexibility, will there be a clamor for it?  Likely so, but I guess it will be nice not to have any "stigma" associated with OIT any longer.  The peanut patch will probably also be out by then and represent a nice alternative for patients that are maybe not as good OIT candidates for one reason or another.

I really don't know what the future will hold. Maybe I'll be using pharma peanut flour, maybe not, or maybe I'll be using a combination of both; and of course there are still all those other food allergens to be dealt with.  But in any case I know I will still be here, working with these amazing families, using the best evidence available, to kick food allergy's butt.

Why I perform oral immunotherapy to foods

After years of thoughtful and careful consideration, I have decided to pull the trigger and offer oral immunotherapy (OIT) to foods.  This decision was not undertaken lightly.  There are a number of reasons why the researchers who conduct OIT in academic settings state why it should not be offered in a real-world setting.  I am completely open to this criticism, and patients need to know that this is a big issue in the world of allergy.  Given this, the decision to offer OIT is wrought with controversy, and I wanted to explain how I arrived at it.  

There is the question as to whether or not OIT provides desensitization or immune tolerance.  If the patient is merely desensitized to the food, and if he/she stops ingesting the food for a period of time after the OIT protocols have been completed, then the patient will become re-sensitized to the food and have reactions if they are exposed to it.  If the patient becomes immune tolerant to the food, that means that after the OIT protocols have been completed if he/she is re-exposed to the food after a period of absent ingestion there would not be an allergic reaction, as the immune system has shifted away from an allergic pathway.  From my understanding of the current state of research, it seems that both outcomes are possible, and it is impossible  at the onset of therapy to identify a patient who would become desensitized from OIT vs. immune tolerant.  To me, this is a moot issue.  I am approaching the situation as follows: once the patient has completed OIT, he/she will be treated as if a desensitization has taken place and immune tolerance has not been reached.  If the patient does not continue eating the food as prescribed every day, then he/she will be brought into the clinic and an oral food challenge will be performed to sort out the issue.  

The second reason stated as to why not to perform OIT is that the therapy may fail.  I estimate that one in every four patients may not reach maintenance dosing for a variety of reasons, including allergic reactions.  This is no different from allergy shots, which all allergists routinely provide to their patients.

The third reason to not perform OIT to foods is the cost of the therapy.  This is certainly valid.  The current recommended treatment for food allergy is strict avoidance.  This, aside from maybe a yearly visit to the allergist and the cost of an epinephrine injector, is free.  There would also be the cost of allergy tests both for diagnosis and possible repeated tests every 1-2 years to monitor the trending of the specific allergy antibody to the food, in case the patient might "outgrow" the food allergy.  This certainly is much cheaper than OIT.  OIT will involve weekly office visits.  It will also involve prescriptions for epinephrine injectors, allergy testing charges, and an oral challenge at the onset of the protocol in many cases.  The cost in out-of-pocket dollars for OIT vs the cost of strict avoidance for treatment of the food allergy must be carefully considered by each family. 

In my mind, here is strongest reason why to perform OIT.  It is the psychological benefit.  Having a food allergy, or multiple food allergies, is difficult.  It is difficult for the child, for the parents, and for other members of the family such as siblings, grandparents, and aunts and uncles.  Multiple studies have documented this.  Studies have also shown that children with food allergies are bullied for having them.  This is the study that finally tipped me, and made me pull the trigger on offering OIT to my patients.  OIT improves quality of life.  Assuming maintenance dosing with OIT is reached, children are no longer afraid of the food or afraid of being bullied because they have a food allergy, and family members have peace of mind when the child is at school or away from home that they will not have a serious allergic reaction to the food when they are not around.  That is why we do it - so the family can take control of their life, and vanquish the fear.  

I promise to carefully lay out the pros and cons of OIT with each and every family.  It is not a miracle cure, and it is not easy, but I do think it can be life changing.  Don't hesitate to give us a call, shoot us an email, or make an appointment.