Immunotherapy

Allergen immunotherapy (IT) is the oldest treatment for allergic conditions, first described over 100 years ago. There are three primary forms: subcutaneous (injection) IT, sublingual (under the tongue) IT, and oral (swallowed) IT.

Subcutaneous immunotherapy

Subcutaneous immunotherapy (SCIT), or “allergy shots,” is the oldest and most familiar approach, often used for environmental allergies like pollen, dust mites, and animal fur. It’s also the only treatment to prevent stinging insect or venom allergies, which can be life-saving. SCIT involves weekly injections of increasing allergen doses into the upper arm, eventually achieving a monthly “maintenance” dose. This can provide long-term protection and may even “cure” the allergy in some cases after 3-5 years. SCIT is effective and safe, though it carries a risk of anaphylaxis, affecting about 1 in 6 high-dose patients.

Sublingual immunotherapy (SLIT) has been popular in Europe for the past 20 years. It involves placing allergen drops or dissolvable tablets under the tongue daily. Used mostly for environmental allergies, SLIT has approved tablets for grass pollen, ragweed pollen, and dust mites. It offers the convenience of home dosing with a very low risk of reaction and similar long-term benefits as SCIT.

Oral Immunotherapy (OIT) is an evolving approach for food allergies. It is a process that regularly exposes the patient to increasing amounts of the foods they are allergic to, with the goal of desensitizing the body and protecting against anaphylaxis from accidental exposures.

It has shown effectiveness in children with milk, egg, and peanut allergies and may “cure” these allergies over time, allowing a normal diet. However, OIT carries a risk of anaphylaxis, and your allergist will determine if it’s a suitable option for your child.

Here are some common questions about OIT
How does OIT work?

After confirming that you have an IgE-mediated reaction to the food, a very important step that requires through consultation, appropriate skin and/or blood testing, and possibly an oral food challenge (OFC), we would start OIT in our clinic with a very small dose of the food, which you would then continue to take at home. Every 2 weeks or so, you would return to clinic for a dose increase, and once we achieve the target dose (300mg of protein for most foods), you would continue to take that daily for at least 1 or 2 years. By gradually increasing the amount of food you are exposed to, and by maintaining very regular intake of the food, your immune system becomes more “used to” the allergen, and less likely to react. This increase in threshold (the amount required to trigger allergic symptoms) and decrease in reactivity (less severe symptoms when reacting) is called desensitization

The short answer is no, it is possible (and in some places common) to offer OIT without an OFC. That said, this leaves the distinct possibility that the person is not truly allergic to the food in question, and that the (expensive and time-consuming) OIT may have been unnecessary. In patients with recent convincing reactions and convincing supportive test results, an OFC may be unnecessary, but in our experience, a baseline food challenge can be incredibly helpful. In some cases, the OFC is successful, confirmed the allergy has in fact resolved, and OIT is then unnecessary. In other cases, the OFC helps the patient understand their allergy better, the symptoms to watch for and the appropriate treatment for such reactions. Additionally, the OFC can establish the allergic person’s current threshold, which can help guide OIT dosing, potentially saving a lot of time, weeks or even months of updosing.

This is a complicated question. For some patients, especially very young children, OIT may in fact be a “cure”, inducing full tolerance and allowing them to eat the food normally afterwards. For most patients, however, OIT is not a cure, but rather a desensitization. In order to maintain desensitization, you will continue to eat the foods you have been desensitized to on a regular basis.

True tolerance means being able eat the particular food as much or as little as you wish without risking an allergic reaction. This is the case for the overwhelming majority of foods we eat on a daily basis. Desensitization means that you are able to tolerate more of the food without reacting, sometimes a lot more, but you have to keep eating the food regularly to maintain that desensitized state. If you are desensitized, and stop eating the food, the allergic symptoms would return quickly unless true tolerance has developed.

This is a very individualized issue, and requires shared decision making. In theory, anyone with a confirmed IgE-mediated food allergy is a candidate for OIT, however it is never that simple. Younger children are better candidates than older children, who in turn are better candidates than adults, where the success rates are fairly low. You will have a full medical examination and review by an accredited Allergist and Clinical Immunologist, who will help determine if OIT could be helpful for you. Families should also be prepared for a daily commitment to dosing at home and regular office visits for many months.

Yes, but your asthma must be very well-controlled, and it will be critical that you follow the Asthma Action Plan you and your allergist have developed very closely. Poorly-controlled or unstable asthma is a major risk factor for more severe allergic food reactions, and it is essential that your airway inflammation and hyper-responsiveness (twitchiness) be minimized throughout. Of course, this should actually be the case for your asthma even if you don’t undergo OIT!

It is actually common and expected to have allergic reactions while going through OIT. Mild reactions, such as an itchy mouth or throat, or mild stomach ache, occur in a majority of OIT recipients, and can be taken as a good sign that your immune system is busy working with the allergen as expected. Severe reactions are much less common,

however there is always a risk of anaphylaxis, and it is important to understand this and be prepared for this possibility. There are several strategies to try to minimize the risk of severe reactions, and we will spend time counseling you on these.

As mentioned above, uncontrolled or unstable asthma is a major risk factor. Viral infections, especially with a fever, can also increase the risk. We will explain how to adjust your dosing if you are unwell. It is important to avoid vigorous activity for a couple of hours after dosing, as this can also increase the risk. We have also learned that fatigue can play a role, so it is important to get ample rest, and to be aware that dose adjustments may be necessary in some circumstances. Very importantly, missing OIT doses increases the risk for reaction, and it is critical to be consistent in the dosing schedule

Of course it is important to maintain good control of any asthma or other allergic conditions throughout the OIT process, as well as any other medical conditions you may have. For the OIT specifically, we may discuss using Xolair (omalizumab) to help facilitate or speed the process. We will also advise you to take a non-sedating antihistamine daily throughout the buildup phase, to help minimize mild allergic symptoms, and to improve the immunogenicity (effectiveness) of the OIT. This is usually stopped once the target maintenance dose is achieved.

Yes, we can treat multiple foods that you are allergic to at the same time. It is possible to build these up simultaneously, although many patients prefer to reach maintenance dosing with one food before starting another.

Yes, you can absolutely undergo OIT even if you have had severe allergic reactions in the past. In fact, studies suggest that patients with lower thresholds or more severe symptoms at baseline may benefit the most from OIT.

Xolair (omalizumab) is an injectable anti-IgE biological therapy that works by inhibiting the allergic reaction process. Studies suggest that pre-treatment with a short course of Xolair allows for a faster and safer OIT buildup, reaching the target maintenance dose in a fraction of the time. As a biological therapy, Xolair is fairly expensive, and as it is not

formally approved for use with OIT, it may not be covered by your insurance provider. This is something we would again discuss and consider on a case-by-case basis.

Certainly all dose escalations should be done in clinic for safety reasons, however it is absolutely possible (and in fact common) to individualize the OIT schedule to optimize convenience. Although it may take longer to achieve maintenance dosing in these cases, that in itself is not a problem.

This is a tricky question, and again highly individualized. In general, the buildup period takes several months, possibly shorter with the addition of Xolair, and sometimes longer depending on the patient’s ability to tolerate the food. Once maintenance dosing is achieved, we would typically maintain daily dosing for at least 1-2 years, after which we may be able to decrease this to 2-3 times per week. In most cases, you would need to maintain regular exposure for the rest of your life in order to prevent a return of allergic symptoms.

Yes, studies suggest that a small percentage of patients receiving OIT develop eosinophilic esophagitis (EoE), a chronic inflammatory condition of the esophagus (feeding tube) which can cause difficulty swallowing, food impactions, vomiting, or stomach pain. This usually resolves after stopping the OIT, and there are even some cases where this is a temporary phenomenon that can be treated medically while continuing OIT. Diagnosing EoE can be a bit tricky, because currently this can only be confirmed by endoscopy and mucosal biopsies with a gastroenterologist, which we would help facilitate if necessary.

This is a fascinating question, and the answer is certainly evolving. If your EoE is very stable and well-controlled, it is absolutely possible to consider OIT to help protect against anaphylaxis, however it is also possible the OIT will trigger a worsening of your EoE. This may result in more frequent need for endoscopy, and potentially more medical treatment for your EoE. Again, these issues need to be factored into the shared decision making process with your allergist.

That’s okay! The current standard of care for food allergy is to avoid the food as strictly as possible, and be prepared to treat any reactions that may occur from accidental

exposures. Your allergist will review the details of your Food Allergy & Anaphylaxis Emergency Care Plan whether or not your chose to undergo OIT, and these allergies will be revisited on a regular basis as always. If you change your mind later, that will lead to another conversation on the issue!

Sure, things change! We are not the same people we were in the past or will be in the future, and our allergies also change over time. There are many reasons OIT may not work out for someone, and those may also fluctuate. Additionally, it is possible that a different OIT protocol was not right for you, or it may be reasonable to consider trying Xolair to help facilitate the OIT. Regardless, this is simply another conversation to have and explore your options!

Yes, we current accept Thiqa, Neuron, NextCare, AXA and Healix insurance plans, and are working to expand our number of partners. The office visits are typically covered or reimbursed for most patients with these insurance plans, however the OIT materials (often capsules containing food powders) are usually not covered directly. We try to switch to “normal” food as soon as possible for convenience. OIT is a fairly new treatment approach, and many insurance providers have not really figured out how to handle this exciting and potentially life-changing option. Our insurance coordinators would try to help navigate this process as much as possible. If not covered by your insurance, you would still have the option of paying directly for OIT.

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