Q & A: Which Patients with Food Allergy Are Candidates for Oral Immunotherapy?
If you have a food allergy, how do you handle it? For some it requires developing strategies to avoid potentially life threatening allergens. By working with an allergist, an oral immunotherapy plan (OIT) should be developed. What is an OIT? Does it work for my allergy? Am I a good candidate for OIT? The answer to these and other questions can be found in a Q&A with Douglas H. Jones, MD, cofounder of Global Food Therapy, co-founder and president of Food Allergy Support Team and director of Rocky Mountain Allergy at Tanner Clinic.
Patients with food allergies can avoid items that may be dangerous — or they can work with an allergist to develop an oral immunotherapy plan that would enable them to safely consume and enjoy previously dangerous foods.
Douglas H. Jones, MD, cofounder of Global Food Therapy, cofounder and president of Food Allergy Support Team and director of Rocky Mountain Allergy at Tanner Clinic, discussed factors to consider when determining if a patient with food allergies is a candidate for oral immunotherapy (OIT) during a presentation at Allergy & Asthma Network’s Global Food Allergy Summit. Healio spoke with Jones to find out more.
Healio: Could you briefly define OIT?l
Jones: OIT is a treatment used for patients with life-threatening food allergies that raises the threshold at which the patient will react to the food. In most cases, that threshold can be elevated so much that patients can consume the food in unlimited amounts safely.
How widespread is OIT’s use in treatment?
Jones: It is hard to know exactly how many allergists are offering it, but it is likely more than 200 allergists now.
Healio: Are patients and other doctors generally aware of OIT?
Jones: Generally, allergists are aware of OIT. Other doctors are likely aware but may or may not know the specifics. I think most food-allergic patients are aware of it, but, again, they may not understand the details. There is still a need to increase awareness and educate people about what OIT is and what it is not.
Healio: What are the advantages of OIT over other treatments?
Jones: Most patients can safely consume the foods that were once life-threatening without avoiding them. We can treat most foods that patients are allergic to, so it is readily available. As the number of allergists doing OIT grows, then access for patients becomes easier.
In times past, many patients had to travel great distances with much sacrifice to have OIT done. In the U.S., that situation is shrinking, as OIT is being more frequently adopted by U.S. allergists. I know many patients abroad are still having some access and availability issues, because it still isn’t common practice in many countries.
Healio: Is OIT particularly beneficial for certain allergies?
Jones: There is documented success for OIT for milk, eggs, peanuts, wheat, soy, sesame, tree nuts (including cashews, pistachios, almonds, walnuts, pecans, hazelnuts, macadamia nuts and Brazil nuts) and shellfish.
Healio: Could you summarize the process for assessing patients to see if they would be good candidates for OIT?
Jones: The main parts of assessing a patient include getting a detailed history to see if it is consistent with food allergy, as well as testing to see if there is evidence to support the history. Many patients will lump food allergies and food intolerances in the same category, and it is important through careful history and testing to discern between the two.
Healio: Can children qualify for OIT?
Jones: To qualify for OIT, the patient needs to have a true allergy as opposed to food sensitivities or celiac disease. They also need to have other health conditions controlled, such as asthma and eczema, and they need to be compliant. Risks, potential complications, benefits and alternative options need to be discussed with the patient. Care should be taken with each patient to minimize risk and maximize benefit. It is important patients communicate with their doctor about their particular circumstances.
Healio: What makes a patient a strong candidate for OIT?
Jones: Strong candidates for OIT include those who have a verified food allergy and who are also able to comply with the treatment recommendations.
Healio: What does compliance require?
Jones: Compliance requires following the protocols as directed by their doctor and being compliant in controlling other potential health concerns such as asthma. Uncontrolled asthma is a risk factor. If a patient is not compliant with asthma treatment plans, then that compromises them doing OIT.
Healio: What would make a patient a poor candidate for OIT?
Jones: Poor candidates include those who are noncompliant with treatment protocols, in addition to those who have uncontrolled eczema, asthma, allergies or other underlying conditions such an anxiety or difficulty following instructions. Further, chronic and uncontrolled disorders of the gastrointestinal tract such as inflammatory bowel disease, irritable bowel syndrome, eosinophilic esophagitis or food protein-induced enterocolitis syndrome may make someone a poor candidate. These conditions do not necessarily exclude patients from OIT, but they need to be addressed, controlled and discussed ahead of time. Again, these are discussions that must take place between the patient and their doctor to see what is most appropriate for their circumstances.
Healio: What does the treatment schedule look like? How much of it is conducted in the office, and how much does the patient need to do at home?
Jones: Treatment consists of starting with microscopic amounts of the allergic food protein and increasing the dose, as tolerated, at the time intervals and dose increments as specified by the treating doctor. Dose increases and challenges are done in the doctor’s office and can take from 1 to 4 hours. Patients then dose at home daily with the same dose that was challenged and tolerated in the doctor’s office.
In general, most patients are visiting the doctor’s office every 1 to 2 weeks for the dose challenges and increases. It takes about 6 to 8 months total, on average. Some protocols can be as short as 3 to 4 months, but others may take up to 1 year or more.
Healio: Are there any side effects?
Jones: The most common side effects include upset stomach, nausea, vomiting, small rash or hives. Anaphylaxis or systemic allergic reactions can occur but are less common.
Healio: How do you measure successful outcomes for OIT?
Jones: Success is measured on whether the goals are achieved or not. In other words, is the patient able to tolerate the doses as specified by the protocols and the goals that are determined by the allergist and the family?
Healio: Do you see OIT’s role in treatment growing?
Jones: Yes, I see OIT continuing to expand greatly. Also, I see the protocols and procedures being more fine-tuned as well. We have come a long way over the last decade in food allergy treatment, and I think this is the tip of the iceberg.
Healio: Are there any areas you’d like to see research into OIT tackle?
Jones: I would like to see more data on the role of biologics in OIT. We have had great success with them in my practice. Overall, they have reduced side effects and made it so that patients could complete protocols in shorter amounts of time. The limiting factor is insurance coverage for these adjunct medications, as they are expensive. But I would like to see more data and potentially official indications so we can use them in a more widespread manner, if that is what the data and evidence suggest. I would also like to see more data on the prevention of food allergy as well as on the role of vitamin D and the microbiome in food allergy and OIT.
Healio: Do clinicians need any kind of training or other continuing education before providing OIT?
Jones: Clinicians need to be well-versed in performing oral food challenges and handling anaphylaxis. They also need to have 24/7 after-hours availability in case patients are in need. Further, they need to know and understand the science behind the procedure and protocols. They need to know the foods and the protocols, and they need to have a plan in place for how to handle patients when problems arise.
Healio: Where can providers go for more information?
We discuss the science, the evidence, history taking, testing, protocols, foods, how to manage side effects and how to plan your office staff and space. We also provide one-on-one support to doctors as they implement OIT so they are not alone in the process. This course can help doctors avoid the pitfalls that may arise and shorten their learning curve significantly so they can feel more confident and naturally offer this potentially lifesaving treatment to their patients safely and efficiently.
We can also offer allergists a software package with built-in protocols that can interface with their electronic medical records and with their patients to enhance the delivery of OIT in a more safe and effective manner. This way, via an app, patients can communicate directly with their doctor, and they can have confidence in the process as well.
These answers are based off my experience but are not intended as medical recommendations or advice. Patients need to work with their own doctors concerning their individual health care needs and specific questions for medical decision-making.
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