Oral Immunotherapy, known as OIT, gives people, mostly kids, the ability to become turn foods that were once life-threatening into some of their favorites. Imagine a child who was never allowed to freely go trick-or-treating be able to dive in to their stash on Halloween night with no issues? Or a child who always had to bring their own food to the birthday party finally be able to join in with the others without being isolated? Stacy Silvers, MD, shares what OIT can do by slowly introducing tiny amounts of the food into the body over the course of 6-8 months.
Michael Carrese (Host): Imagine being the kid with allergies who has to bring his own food to a birthday party instead of being able to enjoy what the other kids are having or not being able to go trick or treating without very close supervising. Then imagine those same children being able to fully enjoy the foods that once were life threatening to them. How is that possible? Well, we’re going to find out today from Dr. Stacy Silvers, a board certified allergist and medical director at Aspire Allergy and Sinus. This is Achoo, the podcast for people with allergies and sinus issues brought to you by Aspire Allergy and Sinus. I'm Dr. Michael Carrese. So Dr. Silvers, just how is it possible to make that kind of dramatic turn around?
Stacy Silvers MD (Guest): Yeah. It’s really a pretty fascinating process. We start by introducing the food allergen in very, very low doses—microgram amounts of the protein. We slowly overtime increase the amount of food the patients are consuming. We can get up to very, very high levels. For example with peanuts, we can get up to 24 peanuts. That’s almost a peanut butter and jelly sandwich these kids can consume.
Host: Wow. So what kinds of allergies can you treat this way?
Dr. Silvers: The most common are peanuts and tree nuts, but we can do this with almost any food allergy assuming it’s the right kind of food allergy. We’re talking about reactions that cause cough, wheeze, hive, vomiting. These IGE mediated allergies, which is the type of allergen that cause anaphylaxis.
Host: How long of a process would this be?
Dr. Silvers: The whole process takes anywhere from six to maybe 12 months depending on how things go. It involves weekly visits or visits every other week to come into the office to increase the amount that you're eating, but then you also will continue to consume that food at home on a regular basis.
Host: So this is like an ongoing maintenance thing. Once you’ve established a better situation with your body’s reaction to that food, you keep it up.
Dr. Silvers: That’s right. The expectation is that you will need to continue to eat these foods on a consistent basis in order to maintain your desensitized state.
Host: So is this essentially the same way that vaccines work?
Dr. Silvers: It’s very similar to how we do allergy shots. You know we’ve done that for over 100 years in allergy immunology where we can desensitize patients to say pollen allergies. Now that is in the form of an injection. OIT is where we’re actually eating the food. You start developing less allergic antibody and different immune cells either increase or decrease depending on what they're doing.
Host: So walk me through it in a little bit more detail. Say I've got a kid with a peanut allergy. You say it’s very small amounts multiple times a day. Break that down a little bit.
Dr. Silvers: So the very first day we have patients come in and it’s a long day. It’s a six to eight hour day where they take up to—for us—almost 13 doses of peanut. Now, those are very, very small amount of peanut that they're actually ingesting for each of those doses. Now after they finish that first day in the office, they will then go home taking their dose of peanut once a day for anywhere from seven to 14 days. At that point if they’ve done well, they’ll come into the office and we will increase that dose. Now, these are what we call up dose visits and they last about an hour. We give the higher dose of the food allergen, watch them, and make sure they're okay. If that goes well they take the new dose every day for a week or two. We continue this process until they're eating full servings of the food.
Host: Are you able to treat more than one food allergy at the same time?
Dr. Silvers: We’ve done up to three foods at the same time. Doing more than that can get a bit tricky because the volume that we ask these patients to eat becomes too much, but you certainly can. For most people, doing two to three foods covers most of their allergens.
Host: How do you know—this isn’t just kids, obviously—but how do you know if you're a good candidate for this or if your child’s a good candidate for this?
Dr. Silvers: That’s a very important question because this isn’t for everybody. It is kind of an optional therapy. In general, those who have what I consider a true allergy would be able to do it. There’s a few things we need to look for. We need to make sure that asthma, if it’s present, is under very good control before we start. Those patients who have another type of allergy already present wouldn’t be a good candidate. That would eosinophilic esophagitis. So this is where kids develop nausea, vomiting, reflux, heartburn, and inflammation of the esophagus. OIT is known to possibly exacerbate that. So we wouldn’t want to sign those patients up.
Host: So there’s obviously a screening process involved here before you’d begin.
Dr. Silvers: Oh, absolutely. Often times there are food challenges involved to make sure that you are actually allergic to some of the foods that you are avoiding, and then a very long conversation about the ins and out, pros and cons of something like OIT.
Host: You mentioned food challenge. Tell me more about that.
Dr. Silvers: So food challenges are the best way to know whether you are actually allergic to a food or not. I see many patients coming in avoiding foods that they don’t really need to be avoiding because a lab test or a skin prick test came up positive at some point. So to really know, we bring those patients into the office and we give them the food and see if they are able to tolerate it or not. We make the decision to do that based on a history, based on skin and lab tests, and then move forward if we find it clinically indicated.
Host: Sounds like you're running a restaurant there with feeding all these people.
Dr. Silvers: Sometimes it’s like that. That’s exactly right.
Host: So what are the risks here? You talked about obviously doing careful screening, but are there some risks with oral immunotherapy?
Dr. Silvers: There are. There certainly are. We are giving these patients foods they are allergic too. There is the risk of having a reaction. In many studies, the risk has been anywhere from 5 to 15% of patients needing epinephrine because they react to their dose. In our patient population, around 6 to 7% of patients need epinephrine at some point. So that is certainly a known risk that we try to minimize the best we can.
Host: With your patients and your experience, how much of a life changer is this for them? Particularly kids I would think.
Dr. Silvers: For patients who are successful with it, it is often times huge. They are able to go out to restaurants without much fear. They are able to go to birthday parties. I've seen so many parents and kids come in just crying with joy after they’ve completed the process. It is just huge for them.
Host: It is a huge problem too. I think the number is about 1 out of every 12 or 13 children now has a food allergy, which has just grown exponentially.
Dr. Silvers: It really has. I mean there is a food allergy epidemic going on. Now, we’re trying very hard to help curb that primarily by introducing these foods early, early on. For some kids, we try to get them to start eating peanut before six months of age, but that still isn’t going to be enough for everybody. Food allergy is going to continue to be a problem. Having options for those families is really, really important.
Host: Sure. So in the end, what's your goal as a provider? You want to see your patients being able to do what with these foods that have been a problem for them in the past?
Dr. Silvers: Well, I've always viewed the goal as being somewhat up to the family. Some family’s goal is to just be protected from accidental ingestion of the food allergen. They don’t have any desire to freely eat say peanut for example. Other families have different goals. They do want to get to very large levels of protection. So we try to customize the goal to what their expectations and wants are.
Host: Yeah. That makes sense. That’s why you work with your practice and people like you who know what they're doing to sort that out. You always have to have kind of a goal and a game plan and have everybody understand what the goal is, right?
Dr. Silvers: Absolutely. Sometimes the goal changes as time goes on.
Host: Well, I would think it would be very satisfying as you were just describing to have a parent and a kid come back in and say, “We don’t have to worry about the peanut thing anymore.”
Dr. Silvers: Yeah. It helps not only with just the food allergen itself, but I see these kids kind of grow in confidence. Their interactions with other kids their age, for example, is much easier. They can go spend the night without much fear at a friend’s house. They don’t have to sit at a separate table in school. It’s good for them in a lot of different ways other than just protecting from allergic reactions.
Host: Yeah, absolutely. That’s great stuff. Well, I'm afraid we’re going to have to leave it there, but I want to thank Dr. Stacy Silvers for being with us today. He’s a board certified allergist and medical director at Aspire Allergy and Sinus. To learn more or make an appointment, please visit aspireallergy.com. If you found this podcast helpful, please share it on your social channels or check out the full podcast library for additional topics that may be of interest to you. This has been Achoo, the podcast for people with allergies and sinus issues brought to you by Aspire Allergy and Sinus. Thanks for listening.
Dr. Silvers is a board certified allergist specializing in environmental and food allergy diagnosis, treatment and prevention. Dr. Silvers oversees our allergy program and protocols, and also leads the food allergy and oral immunotherapy (OIT) program at Aspire Allergy & Sinus. Dr. Silvers is considered an expert in the field of food allergy diagnosis and treatment. In 2019, Dr. Silvers was named Best Allergist in the Statesman's Best of the Best Contest.