patient care perspectives

Oral Immunotherapy: Goals, Expectations, and Future Prospects

by Aikaterini Anagnostou, MD, PhD

Overview

Oral immunotherapy (OIT) is an exciting novel intervention that desensitizes the majority of patients to food allergens and can greatly mitigate the risk of serious allergic reactions with accidental exposures. As such, it represents a step toward reducing the burden of food allergy and can serve as a layer of protection against the risk of anaphylaxis.

Expert Commentary

Aikaterini Anagnostou, MD, PhD

Professor of Pediatrics
Director, Food Immunotherapy Program
Director, Food Challenge Program
Co-Director, Food Allergy Program
Lead, Adolescent Transition for Allergy
Texas Children’s Hospital
Baylor College of Medicine
Houston, TX

“OIT is a valuable option for therapy. For a long time, allergists, in their discussions withparents of food-allergic children, were limited in what they could offer: strict allergen avoidance and prompt treatment of allergic reactions. OIT represents an active option that has the potential to modify the risks associated with the disease and to lessen the frequency and severity of reactions to accidental allergen exposures.”

Aikaterini Anagnostou, MD, PhD

Individuals often tend to think that strict food avoidance is easy to accomplish when, in fact, it is not. Accidental exposures occur for many reasons, including the fact that food allergens may be well hidden. A significant proportion of children have reactions to food allergens despite remaining vigilant about avoiding specific foods, and this is a notable burden.

Parents of children with food allergies may have a range of goals in mind when considering OIT. The most common goal of treatment is to protect their child from accidental exposures, which pose a significant burden and represent a great source of anxiety. Indeed, OIT may offer a layer of protection against the risk of anaphylaxis; however, it is important that OIT is not mispresented as a cure for allergy. As relates to setting expectations, it is important to provide as much detail as possible from the beginning of treatment, to avoid misconceptions.

Some parents might believe that their child will reach a maintenance OIT dose within a few months and will subsequently be able to eat as much of the food as they want, whenever they want. Others may imagine that there will be no need to carry an epinephrine autoinjector once the child is desensitized. Neither is true. The goal of OIT is not to allow for ad libitum consumption of the offending allergen, but rather, as previously stated, to protect the patient against the risk of anaphylaxis. With peanuts, for example, OIT typically protects against exposures to up to a couple of peanuts, although this threshold may increase over time. This might obviate the need to read every product label for trace ingredients, but we still recommend that peanut consumption, outside the therapy dose, be avoided. We also want parents to appreciate that OIT will likely be a lifelong treatment and that the allergic individual will likely need to stay on maintenance therapy long-term. Practical considerations also impact treatment. If there are multiple family commitments and both parents work outside of the home, for instance, OIT might be difficult to work into the family’s schedule. Being on OIT generally involves allowing for a 2-hour window of observation after a dose and also avoiding exercise during that time.

OIT is a valuable option for therapy. For a long time, allergists, in their discussions with parents of food-allergic children, were limited in what they could offer: strict allergen avoidance and prompt treatment of allergic reactions. OIT represents an active option that has the potential to modify the risks associated with the disease and to lessen the frequency and severity of reactions to accidental allergen exposures. Moreover, OIT allows allergic children and their parents to feel more empowered. Ongoing OIT research is focusing on the ability to identify patients who are good candidates with the use of various biomarkers, optimizing strategies to treat those with multiple food allergies, and data to further elucidate and optimize long-term treatment outcomes. Other therapies may also be on the horizon, including biologics that might be used in combination with OIT to improve outcomes.

References

Anagnostou A. Addressing common misconceptions in food allergy: a review. Children (Basel). 2021;8(6):497. doi:10.3390/children8060497

Anagnostou A. A practical, stepwise approach to peanut oral immunotherapy in clinical practice: benefits and risks. J Asthma Allergy. 2021;14:277-285. doi:10.2147/JAA.S290915

Anvari S, Anagnostou K. The nuts and bolts of food immunotherapy: the future of food allergy. Children (Basel). 2018;5(4):47. doi:10.3390/children5040047

Kao LM, Greenhawt MJ, Warren CM, Siracusa M, Smith BM, Gupta RS. Parental and parent-perceived child interest in clinical trials for food allergen immunotherapy. Ann Allergy Asthma Immunol. 2018;120(3):331-333.e1. doi:10.1016/j.anai.2017.12.012

PALISADE Group of Clinical Investigators; Vickery BP, Vereda A, Casale TB, et al. AR101 oral immunotherapy for peanut allergy. N Engl J Med. 2018;379(21):1991-2001. doi:10.1056/NEJMoa1812856

Varshney P, Jones SM, Scurlock AM, et al. A randomized controlled study of peanut oral immunotherapy: clinical desensitization and modulation of the allergic response. J Allergy Clin Immunol. 2011;127(3):654-660. doi:10.1016/j.jaci.2010.12.1111

More in Pediatric Food Allergies

Thumb

Pediatric Food Allergies

Expert Perspectives in Pediatric Food Allergies to Cover Key Topics in Pediatric Food Allergy Treatment

Expert Perspectives

Expert Perspectives delivers health care providers with insights from key thought leaders on the latest advancements and current practices in medic...READ MORE

Thumb

Pediatric Food Allergies

Recognizing and Responding to Anaphylactic Food Reactions

Clinical Topic Updates by Aikaterini Anagnostou, MD, PhD

One of the most important aspects of anaphylaxis is its rapid progression. Knowledge of the potential symptoms of anaphylactic food reactions and f...READ MORE

Thumb

Pediatric Food Allergies

Appropriate Ages for Oral Immunotherapy: Do They Vary by Food?

Patient Care Perspectives by Aikaterini Anagnostou, MD, PhD

Natural history data suggest that some food allergies, such as allergies to cow’s milk, eggs, or wheat, are more likely to be outgrown, compared wi...READ MORE

More In Allergy & Immunology

Pediatric Food Allergies

Reducing The Risks Of Accidental Food Allergen Exposure

Expert Roundtables by Aikaterini Anagnostou, MD, PhD; David M. Fleischer, MD; and Robert A. Wood, MD

Pediatric Food Allergies

To Outgrow Or To Treat: Egg, Milk, And Peanut Allergies

Expert Roundtables by Aikaterini Anagnostou, MD, PhD; David M. Fleischer, MD; and Robert A. Wood, MD

Pediatric Food Allergies

Challenges And Opportunities In The Management Of Pediatric Food Allergy

Patient Care Perspectives by David M. Fleischer, MD