From the Guidelines
Patients with confirmed IgE-mediated food allergies, particularly to peanuts, tree nuts, milk, eggs, or wheat, should be referred to an allergist-immunologist for oral immunotherapy (OIT) evaluation, as it has been shown to improve health-related quality of life and reduce the risk of reactions 1. Ideal candidates for OIT include:
- Those with persistent allergies despite avoidance strategies
- Individuals with severe reactions or anaphylaxis history
- Those whose quality of life is significantly impacted by food restrictions Children aged 4-17 years with peanut allergy may be particularly suitable candidates, as FDA-approved treatments like Palforzia exist for this group 1. Patients should have:
- Stable asthma (if present)
- No active eosinophilic gastrointestinal disease
- Be willing to comply with the lengthy treatment protocol, which typically involves gradually increasing doses of the allergen under medical supervision over months, followed by a maintenance phase OIT works by gradually desensitizing the immune system through controlled exposure to increasing amounts of the allergen, modifying the immune response from an allergic Th2 pattern toward tolerance 1. This therapy requires significant commitment from patients and families, as it involves frequent office visits, daily home dosing, and potential for allergic reactions during treatment. Recent studies have shown that OIT can be effective in achieving desensitization, with a study by Vickery et al demonstrating that low-dose peanut OIT (300 mg/d) achieved similar sustained desensitization to high-dose (3000 mg/d) treatment 1. Additionally, multifood OIT with adjunctive omalizumab has been found to be safe and effective, and can rapidly decrease time to desensitization to multiple foods 1.
From the Research
Referral for Oral Immunotherapy to Allergen
Patients who may benefit from oral immunotherapy to allergen include:
- Children with peanut allergies, particularly those between the ages of 4 and 17, as an oral preparation of peanut allergen (Palforzia) has been approved for immunotherapy in this age group 2
- Individuals with a history of anaphylaxis or severe allergic reactions, as oral immunotherapy may help induce desensitization and reduce the risk of future reactions 3, 4
- Patients with uncontrolled allergic co-morbidities, such as asthma or allergic rhinitis, as these conditions may increase the risk of anaphylaxis during oral immunotherapy 3
Factors to Consider Before Referral
Before referring a patient for oral immunotherapy, consider the following factors:
- The patient's medical history, including any previous allergic reactions or anaphylaxis 5
- The presence of any cofactors that may increase the risk of anaphylaxis, such as exercise, stress, or underlying mast cell disease 5
- The patient's ability to adhere to the treatment regimen and attend regular follow-up appointments 3, 4
Healthcare Professionals Involved in Referral
The following healthcare professionals may be involved in the referral process for oral immunotherapy:
- Allergists or immunologists, who can assess the patient's suitability for oral immunotherapy and monitor their progress 3, 4
- Primary care physicians, who can provide ongoing care and support to patients undergoing oral immunotherapy 2
- Emergency department physicians, who may be involved in the management of allergic reactions or anaphylaxis that occur during oral immunotherapy 6