Dr. Zachary Jacobs: “Why I perform oral immunotherapy to foods” May 4, 2014
After years of thoughtful and careful consideration, I have decided to pull the trigger and offer oral immunotherapy (OIT) to foods. This decision was not undertaken lightly. There are a number of reasons why the researchers who conduct OIT in academic settings state why it should not be offered in a real-world setting. I am completely open to this criticism, and patients need to know that this is a big issue in the world of allergy. Given this, the decision to offer OIT is wrought with controversy, and I wanted to explain how I arrived at it.
There is the question as to whether or not OIT provides desensitization or immune tolerance. If the patient is merely desensitized to the food, and if he/she stops ingesting the food for a period of time after the OIT protocols have been completed, then the patient will become re-sensitized to the food and have reactions if they are exposed to it. If the patient becomes immune tolerant to the food, that means that after the OIT protocols have been completed if he/she is re-exposed to the food after a period of absent ingestion there would not be an allergic reaction, as the immune system has shifted away from an allergic pathway. From my understanding of the current state of research, it seems that both outcomes are possible, and it is impossible at the onset of therapy to identify a patient who would become desensitized from OIT vs. immune tolerant. To me, this is a moot issue. I am approaching the situation as follows: once the patient has completed OIT, he/she will be treated as if a desensitization has taken place and immune tolerance has not been reached. If the patient does not continue eating the food as prescribed every day, then he/she will be brought into the clinic and an oral food challenge will be performed to sort out the issue.
The second reason stated as to why not to perform OIT is that the therapy may fail. I estimate that one in every four patients may not reach maintenance dosing for a variety of reasons, including allergic reactions. This is no different from allergy shots, which all allergists routinely provide to their patients.
The third reason to not perform OIT to foods is the cost of the therapy. This is certainly valid. The current recommended treatment for food allergy is strict avoidance. This, aside from maybe a yearly visit to the allergist and the cost of an epinephrine injector, is free. There would also be the cost of allergy tests both for diagnosis and possible repeated tests every 1-2 years to monitor the trending of the specific allergy antibody to the food, in case the patient might “outgrow” the food allergy. This certainly is much cheaper than OIT. OIT will involve weekly office visits. It will also involve prescriptions for epinephrine injectors, allergy testing charges, and an oral challenge at the onset of the protocol in many cases. The cost in out-of-pocket dollars for OIT vs the cost of strict avoidance for treatment of the food allergy must be carefully considered by each family.
In my mind, here is strongest reason why to perform OIT. It is the psychological benefit. Having a food allergy, or multiple food allergies, is difficult. It is difficult for the child, for the parents, and for other members of the family such as siblings, grandparents, and aunts and uncles. Multiple studies have documented this. Studies have also shown that children with food allergies are bullied for having them. This is the study that finally tipped me, and made me pull the trigger on offering OIT to my patients. OIT improves quality of life. Assuming maintenance dosing with OIT is reached, children are no longer afraid of the food or afraid of being bullied because they have a food allergy, and family members have peace of mind when the child is at school or away from home that they will not have a serious allergic reaction to the food when they are not around. That is why we do it – so the family can take control of their life, and vanquish the fear.
I promise to carefully lay out the pros and cons of OIT with each and every family. It is not a miracle cure, and it is not easy, but I do think it can be life changing. Don’t hesitate to give us a call, shoot us an email, or make an appointment.
