Managing Food Allergies with Oral Immunotherapy: Benefits and Considerations

Announcer:
Welcome to On the Frontlines of Food Allergies on ReachMD. On this episode, we’ll hear from Dr. Anna Nowak-Wegrzyn, who’s a Professor of Pediatrics at the New York University School of Medicine and the Director of the Pediatric Allergy Program at Hassenfeld Children’s Hospital at NYU Langone Health. She’ll be discussing the use of oral immunotherapy in patients with food allergies. Here’s Dr. Nowak-Wegrzyn now.

Dr. Nowak-Wegrzyn:
Oral immunotherapy is one of the ways we can desensitize patients who are allergic to food allergens. It’s allergen-specific desensitization that increases the threshold, which is the amount of food that’s required to produce an allergic reaction.

Oral immunotherapy is a long-term treatment and a big commitment on the part of the patient because it usually takes about six months of visits every two weeks to increase the dose. This is because we have to start from a tiny amount of about three milligrams of protein—or even lower—and then, with every visit, we increase that amount. The patient continues taking the same dose that they tolerated during their supervised visit at home, and then they return to the office for another up dose, usually after six months. So at about 11 visits, the patient can reach the so-called daily maintenance dose, which is the amount of food that they take that is no longer increased. The daily maintenance dose depends on the goals of the treatment and the wishes of the patient. So if somebody is looking for protection, then the daily maintenance dose can be quite low: let’s say 300 milligrams of peanut protein, which is equivalent to about one and a half peanut kernels. But if somebody wishes to eat that food and is really interested in incorporating it into their diet, then we can continue up-dosing until we reach a full serving for their age or at least a partial serving. But once the patient reaches the daily maintenance dose, then they continue. So the maintenance dosing really changes or varies between the patients. Generally, children are more responsive; they have more favorable and quicker responses, so you could check their threshold after a year or two. For older patients with more severe food allergies, it’s likely that they would have to continue daily maintenance dosing for a more prolonged period of time, so about two, three, or even four years. 

Oral immunotherapy is a long-term treatment, and even if the patient reaches the full serving size or reaches their daily maintenance dose, they need to continue following up with the allergists or the physician who is responsible for treatment. This is because when they reach the partial serving or a small amount of daily dosing, you want to continue to monitor their skin prick test and specific IgE levels to get a sense of how much protection they’re getting.

The key takeaway from the discussion of food oral immunotherapy is that this is a valuable option. The efficacy and safety are generally more favorable in younger patients, like toddlers and young children, and those that have milder allergy. It raises the threshold of allergic reactivity to provide some protection. Patients are no longer reactive to trace amounts or small doses of food from unintentional exposures. But this is a long-term commitment that is quite intensive, and with any treatment that requires daily dosing, adherence may be problematic. And there are also lifestyle modifications that are required to minimize the risk of adverse events, so avoidance of so-called cofactors such as exercise, hot showers, or alcohol consumption after taking the dose is important because they may actually interfere or lower the threshold, and the patient might react to the dose they tolerated before. So it’s a long-term commitment; it’s a very valuable approach, but it requires a shared decision between the patient, the family, and the physician that is supervising before embarking on a treatment. And it’s not a short period of time. It’s a commitment for at least a couple of years at the minimum.

Announcer:
That was Dr. Anna Nowak-Wegrzyn talking about oral immunotherapy in food allergies. To access this and other episodes in our series, visit On the Frontlines of Food Allergies on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!