Food allergies upend lives. In children, food allergies can scale back or completely stop participation in birthday parties, organized sports, and summer camps. Parents may need to reduce their work hours and homeschool their children. For adults, grocery shopping or eating out becomes an ordeal. Oral immunotherapy could change that.
Part of the difficulty with food allergies is their sheer unpredictability — a life-threatening allergic reaction can occur at any moment, hidden in what looks to be a “safe” food. For some, this leads to psychological repercussions that include depression and anxiety.
A major problem with food allergies is that there’s currently no cure for them. For the past few decades, all doctors could do was passively prescribe epinephrine pens — the best way to rescue someone who is having a serious allergic reaction — and recommend avoiding the allergenic food.
Up to 80% of kids outgrow milk and egg allergies, but only about 20% of peanut allergies resolve, meaning they become lifelong problems. What’s more, rates of food allergies have exploded over the past 20 years, such that we’re in the midst of a food allergy epidemic. At present, nearly 6 million children and 26 million adults in the United States have food allergies, and every year accidental ingestions result in 9,500 hospitalizations and several deaths.
One treatment option is oral immunotherapy. It basically involves giving patients a tiny amount of the food they are allergic to and then, if it’s tolerated, gradually increasing the dose.
I have been doing oral immunotherapy for my patients with peanut and tree nut allergies for more than two years, both in my practice and as part of the Food Allergy Support Team, an international network of allergists who share oral immunotherapy protocols, answer questions about its intricacies, and publish data from their experiences.
Completing an oral immunotherapy program is a lifestyle game changer. Children can participate in snack time at school without worrying about ending up in the emergency department and can eat packaged foods with ambiguous labeling. Families can venture out to restaurants again. Adults tell me about attending their friends’ backyard barbecues, and being able to grab a drink at a bar that also serves nuts.
A high school sophomore I treated tasted Ghirardelli chocolate at the candy store for the first time, while a junior high student was able to stop seeing her food allergy psychologist. I see oral immunotherapy making a consequential impact, one individual at a time.
In the U.S., around 200 allergists provide their patients with oral immunotherapy. Since it isn’t yet widely available, some parents have gone to great lengths to enroll their kids in these programs. I’ve seen families fly from New York City to the West Coast twice a month. Another family moved from Australia to Utah. They’re motivated because oral immunotherapy gives them a sense of control over food allergies as well as a newfound freedom to live relatively normal lives. For these families, the benefits far outweigh the risks.
To be sure, oral immunotherapy isn’t a miracle cure. After about eight months of it, an individual with a peanut allergy can successfully consume one peanut. That might not sound like a lot, but to someone with a severe peanut allergy it can make a life-changing difference.
The purpose of oral immunotherapy is not so someone can go to a baseball game and inhale a bag full of peanuts. Instead, it provides insurance — a buffer zone — so that in the event of accidental ingestion, the risk that a life-threatening reaction will occur is significantly decreased.
And there are important caveats. Since oral immunotherapy is not a cure for food allergies, individuals should still carry their epinephrine pens. And the treatment isn’t risk free: 10% to 20% of those who start oral immunotherapy stop it due to allergic reactions and gastrointestinal issues, such as abdominal pain, vomiting, and eosinophilic esophagitis, an inflammatory disease of the esophagus. After the treatment period is complete, individuals must continue to take a daily dose of the allergy-causing food for the rest of their lives. It is essentially the “medication” they’re taking to maintain desensitization — individuals who go for a period of time without ingesting the food could lose the protection they gained from it.
Oral immunotherapy could become more widely used if the Food and Drug Administration follows the recommendation of its advisory committee and approves Palforzia, a new peanut-based drug to treat peanut allergies.
In some corners of the allergy world, oral immunotherapy is controversial. A July report from the Institute for Clinical and Economic Review (ICER) stated that due to the lack of long-term data on safety and effectiveness, as well as the risk of reactions with treatment, the current evidence is inadequate to recommend immunotherapy over strict food avoidance. Moreover, ICER’s economic analysis estimated that peanut oral immunotherapy would cost $4,200 a year, a price tag the organization argued was not worth the risks.
An international consortium of food allergy experts pointed out deficiencies in the ICER report: cherry-picking studies, incorporating data only with short-term follow-up, and failing to include clinical trials that demonstrated improved quality of life. These authors were concerned that the negative findings in the ICER report could delay access to oral immunotherapy by the people who need it the most.
One of the benefits of oral immunotherapy is improved quality of life. After completing this treatment, children become less anxious and are more willing to try unfamiliar foods. Parents aren’t as stressed when their kids are left in the care of others, and don’t have to devote as much time to preparing meals. Adults are psychologically reassured when they go on vacation, confidently flying on airplanes, staying overnight at hotels, and visiting foreign locales where the diets are markedly different than back at home.
We’re getting better as a society at dealing with food allergies. Airlines have banned peanuts and tree nuts. Restaurants accommodate diners with food allergies. Laws in California, where I live and work, and some other states mandate that all schools have epinephrine pens on hand. Meanwhile, scientists and doctors are working hard to develop new treatments for food allergies. In addition to oral immunotherapy for peanut allergy, a skin patch for peanut allergy is undergoing FDA review, and oral immunotherapy for eggs is in Phase 2 clinical trials.
I believe that the development of oral immunotherapy for food allergies, including the upcoming FDA approval for peanut oral immunotherapy, is worth celebrating. Until a cure for food allergies is discovered, oral immunotherapy, while imperfect, is the best intervention we have right now.
Charles Feng, M.D., is an allergist at the Palo Alto Medical Foundation and co-founder of the foundation’s Oral Immunotherapy Center.