What is Oral Immunotherapy (OIT)?
Oral immunotherapy is a desensitization treatment in which the immune system is retrained to tolerate food proteins to which it is currently sensitized (allergic). Food-allergic patients consume increasing quantities of the food protein through the gastrointestinal tract daily over the course of months to years. Once the maintenance dose has been achieved, and the body is desensitized to the allergen, the patient is able to consume the allergen without a reaction. In other words, the body is retrained to not react to allergenic foods. This is achieved by consuming increasing amounts of the food allergen by mouth every day.
What is the Goal of OIT (How much protection does OIT give)?
The primary goal of OIT is to be able to offer the patient protection from anaphylaxis by allowing them to ingest a full serving of the allergen without any reaction. OIT would allow patients a better quality of life by allowing them to freely eat food without worry of accidental ingestion or cross contamination of their allergen. Some patients can incorporate the food allergen completely into their diet, if desired. Clinical studies have shown that the IgE trend down, with evidence of sustained unresponsiveness.
What Foods can be done with OIT?
Any IgE-mediated food allergy can be treated with OIT. Our office currently offers OIT for: peanuts, tree nuts, milk, egg, soy, and wheat.
Who are the best candidates for OIT?
Any patient with a food allergy and commitment to OIT is a good candidate. No patient is too allergic to undergo OIT – it just might take the severely allergic person longer to reach their maintenance dose. Rather, patients with severe, life-threatening reactions to food allergens would benefit the most from OIT. Severe food allergies put patients at a high risk for anaphylaxis even without undergoing OIT. The risk of these severe reactions can be significantly decreased, if not completely prevented, with OIT. In addition, OIT is recommend for patients who experience anxiety from food avoidance, cross contamination, and epinephrine/adrenalin experiences. OIT offers increased safety and a better quality of life. OIT can begin for patients as early as 6 months of age.
What excludes a patient from doing OIT?
A history of asthma, environmental allergies and eczema do not disqualify patients from starting OIT. It is important that these symptoms are well controlled before starting OIT because consumption of food allergies during OIT can lead to symptom flaring. Uncontrolled asthma is a contraindication of OIT because strong lung function is necessary due to increased risk of an allergic reaction during OIT.
In general, eosinophilic esophagitis is a contraindication to OIT because the inflammation in the esophagus can be worsened with exposure to ingested allergens. However, we have successfully treated a few patients with OIT that have eosinophilic esophagitis.
How long does the process take?
Generally, patients consume their dose once a day, and up-dose every 10-14 days. It normally takes between 20-25 updoses (about 40-50 weeks) to reach maintenance. However, if a patient requests, Dr. Agrawal may offer twice a day dosing, with updoses every week.
How long does each office visit take?
The first day of OIT consists of a 4-hour day, during which the allergen is consumed in gradual increasing amounts during that time. A typical subsequent up-dose visit will take approximately an hour.
How often do you take the doses?
Doses are consumed once a day, with updoses every 10-14 days. For patients undergoing multiple-nut OIT, it is preferable to do twice a day dosing, with updoses every week.
How long is the Observation Period?
A 1-hour observation period is required to ensure the dose is tolerated. A second hour of low activity should also be observed.
Are there any side effects to doing OIT?
Mild reactions during food desensitization are not uncommon, and may include itching of the throat and mouth, abdominal pain, nausea, vomiting, reflux, or gas. Some side effects are self-limited, and others are managed with dietary modification, antacid medication, antihistamines, or dosing adjustments.
What should I expect from our first consultation with Dr. Agrawal for OIT?
Please bring any previous blood test results, skin test results, and reaction history to your consult for OIT. Dr. Agrawal will review the patient’s data (for both food and environmental allergies) and may require additional testing (blood or skin) at that time. Do not take any antihistamines 3 days prior to the consult in case updated skin testing is needed. If the patient has asthma, a spirometry test may be performed to test lung function and the stability of asthma.
How can I prepare my body to help OIT go smoothly?
It is important that environmental allergies and asthma are controlled prior to starting OIT. These may be managed by daily antihistamines, allergy shots, and/or steroid inhalers for asthma. In addition, the following daily supplements are recommended to help prepare the body for OIT:
- Daily Probiotic - Our office recommends Orthobiotics. Other alternatives are ok, such as Culturelle or Florajen 4 Kids
- Daily Vitamin D3, if advised
What if the patient is sick or has a fever on Day 1 OIT?
The patient will need to be healthy when he/she starts OIT. The Day 1 OIT will need to be rescheduled.
Should routine allergy medications be stopped for Day 1 OIT?
No adjustments to routine medications should be made.
DAY 1 OIT QUESTIONS:
What should I expect on Day 1 OIT?
You will be in the office for approximately 4-5 hours. Be sure to eat a complete meal (breakfast or lunch) before arriving to the office. Doses of the allergen will be given every 15-30 minutes, in increasing concentration, over a course of 4-5 hours. The patient will be monitored continuously to ensure all the doses are being tolerated. Dosing will stop at a predetermined maximum dosage, or at any sign/symptom that the body is reacting. There will be a one-hour wait period after the last dose to monitor the patient.
What should I bring to our Day 1 OIT appointment?
You will remain in the office during the entire visit, so bring snacks and drinks, and items to occupy your time. Please bring your epinephrine autoinjector and asthma inhalers, if applicable
Some suggestions are:
- water, apple juice, milk, etc.
-Snacks - applesauce, fruit, starchy snacks (crackers, goldfish, chips, etc)
-Electronic device, headphones, books, magazines, coloring books, crayons, deck of cards, games, Legos, puzzles, etc.
-Comfortable items (stuffed animal, pillow, blanket)
-Notebook (to take notes, write down dose increases, symptoms, etc), pen, insulated cooler for solution
AT-HOME DOSING QUESTIONS:
How do I take the at-home dose?
Dr. Agrawal will provide a liquid solution and oral syringe for dosing at home. The solution is preservative-free, so it must be kept refrigerated. The solution must be agitated before being measured out.
How often do I give at-home doses?
Doses should be taken once a day, preferably around the same time. However, timing of the dose may be adjusted +/- 3 hours from the previous day’s dose, if needed.
I forgot to take my dose, what do I do?
Doses should be taken daily. However, it is OK to miss a dose occasionally. If there are 2 consecutive days of missed doses, you should contact our office to give guidance on how to adjust the dosage for the next dose.
What guidelines should I follow when taking my doses?
Doses should be taken with a full stomach, and drinking water afterwards is recommended to ensure that the allergen does not linger in the mouth or throat (causing itchy mouth/throat). To minimize any adverse reactions, a 1-hour observation period is requiring during which the body needs to stay calm and cool (no exercise or hot showers). If dosing at night, there should be no sleeping during the observation period.
Can I mix my OIT dose with other food?
Yes, mixing the dose with other food/liquid is permitted. Ensure that the entire dose is taken. Baking/cooking of the OIT dose is not allowed because it may alter the protein of the allergen.
What should I do if I am sick? When should I NOT take my at-home dose?
Always contact our office if you are sick and unsure about dosing. Do not dose on the day of your up-dose appointment. Do NOT dose if you have a fever. Always call and get guidance from Dr. Agrawal if you are sick - this includes vomiting, rash, hives, sore throat, coughing, etc.
What should I do if I have a reaction after my at-home dose?
If you experience a severe reaction or anaphylaxis, immediately follow the Emergency Action Plan. Do not wait for guidance from Dr. Agrawal on how to treat. If you need to administer epinephrine, do so immediately and call 911. Any side effects or reactions should always be reported to Dr. Agrawal right away.
What if I run of out my solution, or if it smells/tastes different?
Call the office if you believe you will run out of your OIT solution before your next up-dose appointment, or if you believe your solution has spoiled. In addition, if you know in advance that you will need extra solution, please request for extra solution at your appointment.
What should I expect on Up-dose appointments?
Up-dose appointments occur every 10-14 days. Arrive to the office ready to take your dose (eat something prior to ensure you have a full stomach). Bring water to help rinse down the dose. Share with the staff any concerns, problems, issues you may have had with dosing during the past 2 weeks. This will help Dr. Agrawal and the nurse practitioners to determine the best incremental up-dose amount. Up-dose appointments typically last about 1.5 hours, which include dosing time and the observation period
When can I eat foods with cross contamination of my allergen?
You must ask a provider when it is permissible to safely consume foods containing cross contamination of your allergen.
Do I have to up-dose every 2 weeks?
We understand that there may be situations where it is not possible to up-dose every 2 weeks (illness, sports, exams, vacation, etc.). If daily dosing continues, up-dose appointments can be flexible, and may be extended if needed.
What is Maintenance?
Once you reach a full serving of the allergen, you have graduated! You will stay at that daily maintenance dose for at least 1 year. There will be no more up-dose appointments. After 1 year of daily dosing, lab tests will be repeated, and dosing frequency may change to 4-5 times per week. During the first year of maintenance, you may not consume above the maintenance dose unless specifically told otherwise.
How much of the allergenic food is the maintenance dose?
Peanut: 5-7 peanuts (5-7 grams actual peanut) or depending on the patient tolerance and goals
Tree nuts: 2-4 tree nuts each, depending on the patient tolerance and goals
Egg, Milk, Wheat, Soy, Fish, Shellfish: Variable, depending on the patient tolerance and goals
How do I graduate from OIT?
After one year on maintenance, you may choose to do a food challenge, consisting of ingesting 2-4x the maintenance dose. If the food challenge is passed, you may consume the allergen freely (above the maintenance dose). However, the maintenance dose will still be required to be consumed daily.
How long do I need to take my maintenance dose?
Maintenance doses should be taken indefinitely. Bloodwork will be checked annually to follow the IgE trend. When blood and skin tests show a significant decline, Dr. Agrawal may suggest a decrease from daily maintenance to only several times a week.
Do I still need to follow the OIT safety guidance once I’m on maintenance?
Patients must continue to follow OIT guidelines while on maintenance. This includes: no exercise or sleeping during the 1- hour observation period, consuming the dose on a full stomach, keeping asthma and environmental allergies in control, and skipping the dose during illness/fever. The providers will be able to give guidance on relaxing these guidelines, after follow-up appointments during the next several years.
Do I still need to carry an epinephrine injector?
Yes. The patient is still allergic, and an epi-pen is still required.
How often are appointments once I reach maintenance?
There will be a follow-up blood test approximately 6-12 months after maintenance is reached. Unless there are concerns or problems, the next appointment will be one year after maintenance. Updated bloodwork and skin tests will be conducted at that time.
Can I do OIT for multiple foods that I am allergic to?
Yes. Because every patient is different, please discuss with the providers if you would like to pursue OIT for multiple foods. Generally, OIT is started for one food/food group initially and other allergens are introduced after several months. All tree nut allergens are started at the same time (ie cashew, pistachio, walnut, pecan, hazelnut etc.). Peanut is started separately from the tree nuts.
Will completing OIT for one food help treat other food allergies?
It is believed that each food OIT program is food specific. Completing one program does not treat other food allergies. However, every patient is different, and there have been cases where tree nuts have been outgrown due to completing peanut OIT.
I am very nervous and scared about ingesting my food allergen. Do you have suggestions on how I can overcome this fear so I can do OIT?
We believe that knowledge is power. The more you learn about OIT and how it works, the more comfortable you will feel about doing this treatment. There are multiple websites and Facebook pages to provide information, research articles, and support for OIT patients. In addition, Freedom Allergy has a patient-led support group on Facebook. We encourage prospective OIT patients to join the group to speak with other families going through OIT so they would be able to share their experiences. Our staff has also compiled a list of patients and their families of all age groups with various allergens that would be happy to speak with you one on one to discuss their experiences with OIT.
Do you OIT for adults too?
Yes – absolutely!
Does insurance cover OIT?
Freedom Allergy accepts many types of insurance. Please call the office to discuss insurance questions.
- Private Practice OIT
- Dr. Agrawal OIT Group
Food Allergy Fix by Dr. Sakina Bajowala
Crushing the Peanut by Katy Patrick (mom of one of our OIT patients)