Oral Immunotherapy

Every patient will first be evaluated to be sure they are candidates for oral immunotherapy. This will consist of skin and sometimes blood tests and a history that indicates a risk for anaphylaxis.

At the first OIT visit, the patient is given a very small amount of the food and observed in the office for an hour to be sure it is tolerated. This dose is then given daily at home and increased every two weeks at an “updose” visit in our office.

Within 12 months or less the patient will usually tolerate the equivalent of one or two peanuts or tree nuts. The amount will differ for other food allergens such as egg or milk. Skin and blood tests will then be repeated to determine if the food sensitivity has decreased. If so, the escalation process can continue up to a full serving size.

The goal is to decrease the patient’s sensitivity to the food to the point that it can be eaten without a reaction.  OIT can reduce the risk of reactions due to cross-contamination by 95 percent. Some patient will eventually be able to consume the food in normal serving amounts without any reaction, but need to remain on a daily maintenance dose so that the desensitization is not lost. It is not yet known whether OIT can be a cure, but studies are ongoing.  OIT may be more effective the in younger children where the possibility of a cure may be real.

Most of the studies have been done with peanut, but OIT can also be done for tree nuts, milk, egg, wheat and sesame. If the patient has more than one food allergy two or more foods can be treated at a time.

Peanut, milk and egg OIT have been shown to desensitize 70 to 80% of patients. In a recent study with a commercial peanut product in patients 4 to 17 years of age, 75% of patients could eat two peanuts by the end of a year. The success rate has been even more impressive in younger children.  A 2021 Canadian study reported that 98% of preschool age children were able to eat the equivalent of four peanuts after one year on OIT. This is in line with our own experience. And a number of studies have reported success with patients being able to eat full serving amounts of the food. Desensitization, however, is different from a cure, and requires continuing a maintenance dose to be effective.

Reactions during OIT can occur but they are mostly mild, consisting of stomach upset or mild hives in our experience. However, more serious reactions including anaphylaxis can potentially occur.

Any updose is always performed in the office with observation for at least an hour. All medications are readily available to treat any reaction. Reactions have occurred  at home as well even with a previously tolerated dose, and parents must be familiar with their anaphylaxis plan and be prepared to treat in the case of an unexpected reaction.

Our updosing schedule is intentionally very gradual and is meant to minimize the chances of a reaction while achieving the same end result over time as more rapid regimens.

A very small percent of patients have been reported to develop eosinophilic esophagitis (EoE), an allergic condition of the esophagus that causes heartburn, vomiting or difficulty swallowing, but it is not clear that this was caused by OIT. This risk may be minimized by drinking fluids after the food dose.

Most insurances cover OIT. Contact our business office if you have questions.

Avoidance of the food allergen is still the standard of care. Most allergists do not perform OIT although there may be more adoption of the treatment now that the FDA has approved a commercial peanut OIT product.

The downside of not doing anything, however, is that peanut and nut allergies tend to worsen spontaneously over time, so that a mild to moderate allergy may become severe. A number of studies have shown that OIT is safe and effective in pre-school  age children and suggest that OIT might reverse the allergic process.

Another benefit of OIT that should not be overlooked is that patients and families report a significantly improved quality of life after treatment. We will always discuss the pros and cons of OIT with the family.