Frequently asked questions
WHAT IS ORAL IMMUNOTHERAPY (OIT)?
Oral immunotherapy is a treatment in which ingestion of a small amount of a food allergen on a daily basis leads to a state whereby an allergen can be eaten without having a reaction. This is known as desensitization.
WHAT IS THE GOAL OF OIT?
The goal of oral immunotherapy is to be able to eat products that contain the allergen without the constant fear of having a reaction.
IS OIT A CURE FOR FOOD ALLERGIES?
No. It is not a cure because when/if the daily dosage is stopped, many individuals may return to the allergic state and thus lose the desensitized state. Current research studies are looking at ways to induce immune tolerance, i.e. the ability to eat the food without reaction after stopping the daily dosage.
WHO ARE GOOD CANDIDATES FOR OIT?
Individuals who wish to reduce the risk of an allergic reaction in the event of accidental ingestion and will be compliant with the dosing regimen.
WHO SHOULD NOT PARTICIPATE IN OIT?
-Individuals who are at higher risk of having an allergic reaction during immunotherapy are not good candidates. This includes those with poorly controlled or severe asthma. Those who have severe eczema and active eosinophilic gastrointestinal disease are also not ideal candidates. You and your allergist should discuss if you have any of these conditions.
-Oral immunotherapy requires several visits to the office for escalation in dosing. Those who are unable to comply with required follow up visits are not good candidates for immunotherapy.
-Those who do not feel comfortable, are unwilling, or unable to inject epinephrine into themselves or their child in the event of anaphylaxis are not good candidates.
HOW MANY VISITS TO THE ALLERGY OFFICE ARE THERE?
The number of visits to the allergy office will depend on the number of allergens used, the target maintenance dosage and whether or not you use Xolair (explained later). This will be determined after your consultation with our OIT team. With Xolair, there could be as few as 3 appointments in the allergy office. Without Xolair there could be as few as 14 appointments in the allergy office. The exact duration will vary by individual depending on adjustments in dosage that may need to be made if there are symptoms, illness, and/or other reasons why dosing needs to be adjusted. We are able to individualize therapy to maximize safety, comfort and convenience.
WHAT DOES THE VISIT SCHEDULE LOOK LIKE IF I DO OIT WITH XOLAIR?
There is usually an initial visit to discuss the OIT protocol in more detail and answer any questions. This is called a “screening” appointment.
Typically OIT in combination with Xolair includes Xolair injections once a month for three to five months depending on allergens to be included in OIT and the desired maintenance dose of those allergens. The introduction of foods occurs at the third Xolair injection, this is called the IDED. The IDED will be done to determine the starting dose for home dosing. At this visit, we will carefully feed you or your child a specified amount of the allergen(s) by mouth and observe for any reaction. The amount of protein given to you or your child will double approximately every 15-30 minutes up to a maximum dose. This dose varies depending on type and number of allergens. The dosing schedule is individualized and specially made for you or your child. It is possible in some cases to reach the maintenance dose at the IDED. Once the maximum tolerated dose is given, you or your child will be observed for approximately 1-2 hours. If there is no evidence of an allergic reaction, you and/or your child will be sent home. This visit may last 4-6 hours or longer if you and/or your child has a reaction.
After the IDED, if the maintenance dose has yet to be reached, the highest tolerated dose reached at the IDED will be given at home daily for approximately 2 weeks. You and/or your child will be asked to return approximately every 2 weeks to the allergy office to have the dose of daily protein increased as appropriate until the maintenance dose is reached. Each dose escalation appointment will last approximately 1 1/2 hours. Our protocol is designed to reach a maintenance dose of 300mg protein minimum (approximately 1-2 nuts depending on the nut) but can be higher according to individual preferences and goals. The maintenance dose is typically achieved within 8 weeks of the final Xolair injection, although can be reached as early as the IDED.
After reaching the maintenance dose, the follow-up visits will be less frequent (approximately every 6 months). You or your child will continue to consume the protein on a daily basis unless otherwise instructed by allergy staff. Follow-up visits could entail repeat skin and blood testing. There could also be an oral food challenge visit where a higher dosage of protein will be given (up to 4-5g protein total). The follow-up visits could happen with your primary allergist if you wish.
WHAT DOES THE VISIT SCHEDULE LOOK LIKE IF I DO OIT WITHOUT XOLAIR?
There usually is an initial visit to discuss the OIT protocol in more detail and answer any questions. This is called a “screening” appointment.
The 1st treatment visit is called the initial dose escalation day (IDED). The IDED will be done to determine the starting dose for home dosing. We will carefully feed you or your child a very small amount of the allergen(s) by mouth (usually in the form of flour/powder) and observe for any reaction. The amount of protein given to you or your child will approximately double every 15-30 minutes up to a maximum dose. This dose varies depending on type and number of allergens. Once the maximum tolerated dose is given, you or your child will be observed for approximately 1-2 hours. If there is no evidence of an allergic reaction, you and/or your child will be sent home. This visit may last 4-6 hours or longer if you and/or your child has a reaction.
After the IDED, the dose will be given at home daily for approximately 2 weeks. You and/or your child will be asked to return approximately every 2 weeks to the allergy office to have the dose of daily protein increased as appropriate. Each dose escalation appointment will last approximately 1 1/2 hours. The initial doses will be given in the form of a flour. There will be a point at which time the home dosage can be given as the actual food (i.e. nuts or nut butter). Our protocol is designed to reach a maintenance dose of 300mg protein minimum (approximately 1-2 nuts depending on the nut) but can be higher according to individual preferences and goals. It will take a minimum of about 28 weeks to reach this dose (with one food and no need for dosing adjustments).
After reaching the maintenance dose, the follow-up visits will be less frequent (approximately every 6 months). You or your child will continue to consume the protein on a daily basis unless otherwise instructed by allergy staff. Follow-up visits could entail repeat skin and blood testing. There could also be an oral food challenge visit where a higher dosage of protein will be given (up to 4-5g protein total). The follow-up visits could happen with your primary allergist if you wish.
WHAT IS THE RISK OF AN ALLERGIC REACTION DURING OIT?
Studies show that many patients will exhibit symptoms at some point during the immunotherapy process. Reactions more commonly occur during the dose escalation phase (also called the build-up phase), although they can occur at any time during therapy. The majority of reactions are treated successfully with an antihistamine only. The most common reactions include an itchy mouth and mild abdominal pain and/or vomiting. A recent chart review of oral immunotherapy with peanut conducted in 5 private allergy clinics reported epinephrine use was uncommon (0.2% to 0.7%...that's about 2 to 7 out of 1000 doses). Although this is reassuring data, you or a caregiver should always have readily accessible epinephrine and follow your emergency food action plan. (Wasserman et al, J Allergy Clin Immunol Pract. 2014 Jan-Feb;2(1):91-6)
IS A CLINICIAN AVAILABLE IF I HAVE A REACTION OR URGENT DOSING QUESTION WHEN I'M NOT IN CLINIC?
Yes, a clinician (NP, PA, or MD) is available for urgent medical questions until you have been at your maintenance dose for 6 months. After you have been at your maintenance dose for 6 months we recommend you direct urgent medical questions to your primary allergist. As always, you never need anyone’s permission to use epinephrine. If you have an emergency that requires epinephrine, please inject, call 911 and get yourself safely on the way to the emergency room.
WHAT FOOD ALLERGENS ARE OPTIONS TO BE INCLUDED IN OIT?
We are currently offering oral immunotherapy (without Xolair) to peanut, hazelnut, almond, brazil nut, cashew/pistachio, walnut/pecan, macadamia nut, pine nut, egg, cow milk, wheat, barley, oat, sesame, flax seed, chia seed, sunflower seed, chickpea, and soy.
We are currently offering oral immunotherapy in combination with Xolair to peanut, hazelnut, almond, brazil nut, cashew/pistachio, walnut/pecan, macadamia nut, pine nut, egg, cow milk, wheat, barley, oat, sesame, flax seed, chia seed, sunflower seed, chickpea, lentil, coconut, soy, white fish, pink fish, shellfish.
*If you do not see an allergen on the above lists, please feel free to ask!
ONCE I OR MY CHILD REACHES THE MAINTENANCE DOSE, WILL I/MY CHILD HAVE TO EAT THAT EVERY DAY FOREVER?
Probably not, but for the immediate future, yes. The goal of our protocol is to induce a desensitized state. This means you have to eat the food to continue to tolerate it without having a reaction. If you avoid the food you were desensitized to and then come back and eat it without reaction you are not just desensitized, you are scientifically tolerant. Research is currently being done to determine the safest and best way to achieve scientific tolerance. We will let you know at follow-up appointments as research emerges the safest and best dosing plan.
HOW DO I START THE OIT PROCESS?
If you are interested in proceeding with OIT at the National Allergy Center, please schedule a complimentary phone consult by completing the form on our website, www.nationalallergycenter.com or call 1-855-FIND-OIT (855-346-3648).
