Dr. Jacobs: Why I (still) perform oral immunotherapy to foods

Dr. Zachary Jacobs: Why I (still) perform oral immunotherapy to foods, August 14, 2015

I’ve been asked to give an update on my oral immunotherapy (OIT) for food allergy program since beginning it towards the end of last year. OIT has changed my life, and I’m not even food allergic. It has become the single most rewarding part of my professional practice. It has also become the most time intensive part of my practice. The OIT program is mine, and mine alone. Because the parents and children in the OIT program put their faith in me and entrust me with so much, I basically do it all to ensure no errors are made. I’m available to them 24/7 by cell phone. I measure every bit of flour. I make the peanut solutions. I even make the labels on the bottles. I talk to the family and perform an exam prior to each up-dose.  As the program picks up steam, I probably will not able to keep up on all this and will eventually have to let go of some of my responsibilities.  I will not become less accessible, though.  That is the cornerstone of my OIT practice.

But you know what? All of this extra work is worth it. These kids are amazing. These OIT families are amazing. The lengths that they will go, the commitments that they will make, to provide their child a life free of the anxiety that comes from being food allergic is inspiring to me as a parent.  The children’s bravery at bucking the trend, at going along with something that their prior allergist might be against, is pretty awesome.  Here is a point of emphasis:  These kids are cool.  Really cool.

I’ve also become much more adept at food challenges. Prior to my OIT life, the main reason to do a food challenge was to see if a child had outgrown their food allergy. Now, it is just as common for me to perform a food challenge to confirm the food allergy prior to undergoing such a time intensive process. As exciting as it is to see a food allergic kid progress through oral immunotherapy and tackle the food head on, it is just as exciting and rewarding to have a child pass a food challenge to something that they previously thought they were allergic to–and leave the clinic that day with complete and total freedom from that food’s effect on their life. I have seen a kid with a peanut IgE of 12 and ara h2 IgE of 5 pass his challenge with flying colors.  I have also seen a kid with a walnut IgE of 0.6 fail a challenge on the first dose.

We have had minimal problems to date with the therapy, but the program is still in its infancy really. The most common side effects are some mild GI issues.  Probably the biggest one that I underestimated prior to starting this is the anxiety.  It is something that the kids, especially the older ones, can really struggle with.  The other thing I underestimated was how much peanut allergic kids seem not to like the taste of peanut (go figure).

My OIT practice is still small I think compared to most of the clinics around the country that are offering the therapy. I think I have around 15 patients right now. However, almost month-to-month, there is increased growth, excitement and interest in the program. Nearly every week now, I am either starting a patient on oral immunotherapy or performing a food challenge to see if a child would benefit from it.

OIT works. I don’t think that any of the arguments that contend for more research prior to it being offered in practice, especially in regards to peanut, hold any water. Research should continue, don’t get me wrong. Research on allergy shots for environmental allergies continues even while subcutaneous allergen immunotherapy is widely practiced in the community. The research is there to fine-tune the practice and answer questions as they arise. But fundamentally, I believe that oral immunotherapy to foods is safe and effective.

I’ve always tended to believe that the most effective argument against oral immunotherapy was along the lines of the cold hard economics of it. The number of food allergic kids required to do food oral immunotherapy to prevent one food allergy related death is probably quite high (meaning the number needed to treat to prevent a death would maybe be too high to justify the price of the therapy, at least on a populational level). But, this economic argument that some allergists postulate no longer holds water either. Because a peanut flour pill has been fast tracked by the FDA. If one thought that the economics of OIT didn’t make sense using run-of-the-mill peanut flour that can be bought anywhere, guess what will happen when we use “pharmaceutical grade” peanut flour that the patient is prescribed?  The cost of oral immunotherapy will be astronomical. Furthermore, when the peanut pill is eventually approved by the FDA, the same questions that hold many people back from offering OIT such as what’s the most effective dosing protocol, desensitization versus tolerance induction, and side effects, will all still be out there. However, since the peanut flour will suddenly be “FDA-approved” using a more regimented protocol with likely less flexibility, will there be a clamor for it?  Likely so, but I guess it will be nice not to have any “stigma” associated with OIT any longer.  The peanut patch will probably also be out by then and represent a nice alternative for patients that are maybe not as good OIT candidates for one reason or another.

I really don’t know what the future will hold. Maybe I’ll be using pharma peanut flour, maybe not, or maybe I’ll be using a combination of both; and of course there are still all those other food allergens to be dealt with.  But in any case I know I will still be here, working with these amazing families, using the best evidence available, to kick food allergy’s butt.

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