New Consensus Recs for Oral Immunotherapy in Food Allergies

— Allergist Zahida Maskatia, MD, shares how the guidelines will change practice

A photo of Zahida “Rani” Maskatia, MD

New published in the Journal of Allergy and Clinical Immunology offer guidance on preparing patients for the use of oral immunotherapy (OIT) for treating food allergies.

is the medical director of Latitude Food Allergy Care, a network of several clinics in New York and California that provide OIT. Maskatia, who was not involved with crafting the recommendations, spoke with app about the new guidelines and how they will impact current practices. This interview has been edited for length and clarity.

What are some of the most important components of these new guidelines?

Maskatia: It's well known that patients with food allergies can have impaired quality of life due to the risk of accidental exposures, and oral immunotherapy can help to alleviate some of their anxiety by decreasing the risk and severity of accidental exposures. However, it's a treatment that has potential to cause serious side effects if not done properly, and so we've all agreed for a long time that we need more standardization in this field to help improve patient outcomes.

We use shared decision making to try to understand our patients' goals and preferences, but it really wasn't clear which key elements we needed to review during those discussions and the consent process. So, this is really the first study to develop these consensus-based guidelines to help inform and prepare patients and caregivers as they start their OIT journey.

What kind of anxiety do allergy patients and their families face?

Maskatia: This is one of the most common things we hear from our families and patients that have food allergies. Eating is something, obviously, that we do multiple times per day, and so there's anxiety every time someone is eating, especially outside of safe places like their homes -- they worry that they might accidentally have an exposure to the foods that they're allergic to. So, it really does seem to become part of day-to-day life for some of our patients.

That's where this desensitization strategy, the oral immunotherapy, can really help improve their lives for the better -- by decreasing the chance of having an accidental exposure and also decreasing the severity of a reaction if there is an accidental exposure.

What kind of need was present to warrant these guidelines and standardization?

Maskatia: So, basically, just anything that gives us more concrete guidelines about which patients might benefit from it, what topics we need to review with our patients before they start it. And I think, most importantly, helping to kind of delineate contraindications and risk mitigation strategies during treatment to help prevent serious reactions with oral immunotherapy. I think those were the most important things that came out of the guidelines.

What are some of the roadblocks that patients can encounter while seeking OIT?

Maskatia: It is a time-consuming treatment and we have had some patients who have decided to stop oral immunotherapy due to reactions, or even due to scheduling issues. It is a time commitment that some of our patients aren't able to continue with, and so we have had some people who have had to stop. But, overall, it really does have a lot of potential to improve the lives of our food-allergic patients.

It's a long-term, potentially lifelong, commitment, and that can definitely be daunting for some of our patients. There's a required rest period, which can be challenging for some of our patients who have, for example, busy sports schedules. And with this therapy, we do see frequent reactions during treatment, the vast majority of those are mild and decrease with time, but some of our patients do choose to stop because of side effects as well.

What about some challenges you face?

Maskatia: It has been a challenge because the only FDA-approved option is for peanuts, which is great for peanut allergy, but we have so many patients who have other food allergies or have multiple food allergies. So that's why we've had to create our own protocols for all of the other foods that people might be allergic to. The other big challenge for us has been insurance coverage. This is a newer therapy and insurance companies really haven't caught up, so we don't have the codes that we would like for this specific therapy. It can also be hard to get the right reimbursement when you offer this therapy.

How do you think the new guidelines will address some of these current needs?

Maskatia: The main thing is standardizing the things that we need to review for good shared decision making with our patients and for informed consent. Because this has been a therapy that we haven't had these kinds of consensus guidelines, there's been some heterogeneity in how it has been practiced. I know that, for me, as a food allergy doctor who's done a lot of oral immunotherapy, it's very helpful to see what has been determined as, for example, an absolute contraindication by the experts.

There were a couple of things that 100% of the allergists agreed should be an absolute contraindication -- uncontrolled asthma, for example, absolutely is something that would be an absolute contraindication here at Latitude as well. We would not treat someone who does not have well-controlled asthma. Starting this treatment during pregnancy was another one. The last one that was one that all the allergists agreed would be a complete contraindication would be unwillingness to use epinephrine. We shouldn't be offering this therapy to a family that does not feel comfortable giving their child epinephrine, because there is a chance that you can have a serious reaction with the therapy, and so that family does need to be willing to give epinephrine if it's indicated for a serious reaction.

What do you hope to see following these new guidelines?

Maskatia: Definitely the biggest thing in the entire field of food allergy treatment, especially oral immunotherapy, has been trying to kind of figure out ways to make it more and more safe. The honest truth is we're giving something to patients that they are very allergic to, and so there is a risk of having a serious allergic reaction. That definitely has been the most concerning part of all of these treatments. Now, that being said, this is the same risk that you have when you get allergy shots.

We're always looking for ways to make oral immunotherapy safer. The recommendations listed in these guidelines, things that we're already doing, like having patients follow a rest period, making them aware that things like NSAID [non-steroidal anti-inflammatory drug] use might make them more likely to have a reaction, or significant fatigue might make them more likely to have a reaction. So, of course, informing patients better about those types of cofactors that can make them more sensitive to their dose. But then also there's another branch of it, which is that there are treatments that are coming out that hopefully will make this a safer process.

What do you think clinicians should take away from these new guidelines?

Maskatia: Honestly, it's still not widely realized that there are treatment options even for food allergy -- for decades, all everyone would ever recommend is avoid it, carry your EpiPens. Just making sure that people are aware that treatment options do exist and having those patients talk to, not only a board-certified allergist, but ideally a board-certified allergist who actually has experience with these treatments -- because only a small percentage of allergy doctors, even board-certified allergists, are actually even offering these treatment options. So, number one, increasing awareness around it.

I do think that one of the hesitations of our referring doctors is that there was so much heterogeneity when it came to actually doing OIT and there wasn't this standardization. And so these guidelines are hopefully going to help make things standardized. We know that that's how we improve patient outcomes -- by having guidelines that all oral immunotherapy doctors can follow, to make sure that patients are aware of what they're getting into, making sure that they are well informed, but then also having these strategies to help decrease the chance of serious side effects, which can happen.

I'm going to admit I might be a little biased here, but we've made a difference in a lot of people's lives with oral immunotherapy. I'm super excited that it's just becoming more and more accepted and widely available to our patients. So anything we can [do to] keep moving in the direction of making it, not just a safer process, but more accessible and more accepted -- that's going to be great news for our food allergy patients.

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    Elizabeth Short is a staff writer for app. She often covers pulmonology and allergy & immunology.