What is Oral Immunotherapy (OIT)?
Food Allergy OIT or Oral immunotherapy is a method of inducing your immune system to tolerate a food that it is currently over-reacting to. In OIT, allergenic foods are introduced into the system in gradually increasing amounts. The goal is to be able to eventually consume the food regularly without experiencing any allergic reactions.
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Is OIT for you?
Perhaps our story may help you decide. There are many pros and cons when deciding if this treatment is the right decision for your family. I’d like to share our family’s experience with OIT treatment for food allergies and how it has impacted our life. Both our son and daughter are allergic to multiple foods and have completed clinical trials for desensitization.
KEIRA’S OIT STORY
Multi-allergen Trial with Xolair (7 months)
Keira is allergic to milk, peanuts, cashews, pistachios, sesame seeds, shrimp, and salmon. The milk and nuts caused an anaphylactic reaction in her, including itching/swelling of the lips and tongue, hives, stomach-ache, vomiting, wheezing, and coughing. The sesame seeds, shrimp, and salmon had a more mild symptom of itchy mouth.
Keira (9 years old) participated in a 7 month multi-allergen oral immunotherapy (OIT) with omalizumab (Xolair®) clinical trial led by Dr. Kari Nadeau at Stanford. In this trial, we were able to include up to 5 allergic foods, however this did not include shrimp and salmon. Her allergens for this trial were milk, peanuts, cashews, and sesame.
Xolair is a medication originally designed to reduce sensitivity to allergens. In the trials, they are researching how it affects OIT.
The first 3 months consisted of Xolair injections so that future allergen dosing could be done at an accelerated pace. The last 4 months consisted of home dosing with her allergens starting at a minuscule amount and increasing every 2 weeks. For each dose increase, we would go in to the clinic.
For the most part, dosing was easy with minimal reactions. She would take an antihistamine, Zyrtec, 1 hour before dosing as well as a daily probiotic. The most difficult time was when she started to have random vomiting seemingly for no reason. These episodes occurred anytime of the day and didn’t seem to coincide with when her last dose was taken. For example, she could have her dose at noon the previous day and vomit the next morning. She was advised to take Pepcid before dosing to see if it would help. Thankfully, these random vomit episodes stopped after 1-2 months.
In her own words, this is her story:
After graduating from this food allergy OIT trial, Keira is now desensitized to 2 grams of protein for each, except for the shrimp and salmon. She has no reaction, not even an itchy tongue/mouth/throat to these amounts of allergic foods. For one year, she stayed on her maintenance amount and took her daily doses of 2 grams in real foods without pre-dosing with an antihistamine. We found it easiest to combine all her allergens and some additional fruit into a delicious smoothie.
How much is 2 grams of protein in real food terms?
- 0.25 cup milk or 1 Go-gurt tube or 0.3 cup ice cream or 1 inch cube of original cream cheese or 1/4 string cheese
- 8 peanuts or 1.5 teaspoons peanut butter or 1 Reese’s peanut butter cup
- 7 cashews or 2 teaspoons cashew butter
- 7 pistachios
- 4 teaspoons sesame seeds
Be sure to pin it:
After the 1 year on maintenance, she now takes less of most allergens. She doses daily with 2 peanuts, 1 cashew, 1 teaspoon sesame tahini, and 0.25 cup milk. However, the goal for us was to eat like non-allergic people, so sometimes we push the limit, especially with the milk. Keira has eaten an entire 7″ mini cheese pizza with no reaction whatsoever. She also eats ice cream cones, frozen yogurt, and at dessert buffets without measuring allergen amounts. Food allergy OIT is truly amazing.
As for the shrimp and salmon, she is working on desensitizing those in the individual innovative clinical care program (not part of a clinical trial).
CONNOR’S OIT STORY
Peanut OIT Trial (3 years)
Connor is allergic to peanuts, cashews, almonds, hazelnuts, and walnuts. He is anaphylactic to these and we’ve had to use EpiPens in the past. When he got accepted into a 3 year peanut trial at the age of 10 years old, we were ecstatic to begin this road to freedom.
The 3 years of this peanut trial broke down into 3 phases: dose escalation, maintenance, and tolerance.
The first year of OIT, he started with a minuscule amount of peanut flour and increased every 2 weeks. He would take Zyrtec one hour before his dose of peanut flour mixed into applesauce. He would dose at home for 2 weeks, then go in to the clinic for a dose escalation. He continued this for a year. Dosing was pretty easy for him. For a few days after each escalation, he would get a reaction of an itchy mouth for about half an hour. He escalated as high as 4000mg of peanut protein flour, which is equivalent to about 16 peanuts. There are typically 2 peanuts inside each pod/shell.
The second year, he ate a daily 4000mg peanut protein flour mixed with applesauce or fruit smoothie.
The third year is where it got interesting. He could have randomized to a lower dose of peanut or switched to the placebo group which was oat flour. We are pretty sure he was randomized into the placebo group. With 3 months of this daily placebo dose, he failed his food challenge in the clinic. He could no longer tolerate the 4000mg and got a serious reaction. Two hours after his dose, he felt shortness of breath. Thankfully, with medication, he recovered.
With the failed food challenge, came the graduation from this food allergy OIT trial. Connor started daily dosing again, this time with real peanuts. He eats 2 peanuts a day. He has also started OIT as part of the individualized clinical care program for his other nut allergens.
Why We Chose Food Allergy OIT
After years of strict avoidance, a few occasions requiring epinephrine and Emergency Room visits, we wanted to be pro-active about our children’s food allergies. After all, high school life would be here before we know it and the kids would be more independent without us parents always hovering over them for protection. I wanted them to be safer in this world, to not always have to worry about the cross contamination of foods and what other’s have touched. Emotionally, I wanted them to feel like any other kid, to have the freedom to share food or try something new without worrying about life and death all the time. Life with food allergies is stressful. Sometimes we feel helpless. So we chose OIT.
Pros of OIT
It’s LIFE CHANGING. We don’t need to worry about cross contamination anymore. Allergic reactions due to eating out have all but disappeared. We don’t need to ask to speak to the chef.
Kids can now participate in school parties and birthday parties and eat what others eat. I don’t need to supply emergency allergy safe alternative treats to the teacher. They’re no longer singled out!
My kids can go for sleepovers at their friend’s house now. And there’s so many more pros I can’t even name them all. The quality of life is just so much better. A huge weight has been taken off our shoulders.
Life has less stress and less anxiety. Doesn’t that make the entire family healthier?
Even washing dishes is easier because I don’t need to worry about which plate had milk on it. Cooking is easier because I can make a sandwich with a slice of cheese and not have to wash my hands before opening the fridge. I could go on and on, but I won’t.
Cons of OIT
OIT in clinical trials requires a huge time commitment. Let me underscore HUGE. Before starting OIT in most clinical research trials, you must confirm the allergic severity with food allergy testing.
The double blind food challenges required 2 full days for each food. Every 2 weeks, we go in for a dose escalation appointment which took about 3 hours. Every 3 months, we had a skin test done and a blood draw. The blood draws were typically 4 vials worth. These were taken for research since it was a clinical trial. At certain transition points during the trial, we went in for double blind food challenges again (for example, at the transition from year 1 of up-dosing to year 2 of maintenance for the 3 year peanut trial).
To minimize an allergic reaction, they recommend no exercise for 2 hours after dosing.
There’s always risk of an anaphylactic reaction. With my daughter, she required epinephrine injections on a few of her food challenges. However, I felt she was in good hands and trusted the ability of the doctors, nurses, and clinicians to take care of her. The clinic was located in the hospital and it was the best place for it to happen. With a pre-dose of an antihistamine, Zyrtec, reactions at home remained small. There was never more than 45 minutes of itchy mouth.
Not everyone is a good candidate for OIT either. You may be too allergic or not allergic enough. This will be determined by your IgE levels, that’s the allergen-specific immunoglobulin E (IgE) from your blood test and/or skin testing and/or past medical history.
Consider the Age for OIT
Age should definitely be considered when starting treatment. My kids were a bit older, at 9 and 10 years old, so they understood what was happening and that taking the doses would help them in the long run. You can’t really explain that to a younger child. Blood tests are difficult, you have to stay very still. Xolair injections are also tough. The needle stays in for a while and there was an injection into both arms at the same time. I remember my daughter asking for the cold and vibrating Buzzy bee to make it easier. Consider if your child can willingly eat the dose everyday and can tell you any symptoms.
Do all OIT’s require injections?
I don’t know the details about what OIT in private practice is like. However for our family, my daughter’s trial included Xolair injections to speed up the dosing escalation process. My son’s trial did not include Xolair injections. You could say that it was done in a more “natural” way. The blood draws for both of their trials was because it was a clinical trial and the blood was collected for research.
There are clinical trials for all ages. Children, teens, and adults. Each trial has their own eligibility rules.
Private Practice OIT
OIT is also available through a limited number of private practices. Most allergy doctors still do not offer this treatment.
Is Oral Immunotherapy the Cure for Food Allergies?
Will the daily doses have to be taken forever? We don’t know. Researchers are currently working on these answers. However, we do know that all the effort put into desensitization is worth it to be safe out there in the real world and to have a better quality of life. We feel so fortunate to be a part of Stanford’s trial to help allergy research move forward.
For further reading:
- Stanford’s research and clinical trials: Sean N. Parker Center website.
- Food allergy research: FARE website.
- Clinical Predictors of Allergic Side Effects During Peanut Oral Immunotherapy
- What Happens to Food Allergies After Treatment with Oral Immunotherapy?
What do you think? Could OIT be in your future? Share your thoughts in the comments.