Oral Immunotherapy

Frequently Asked Questions

Oral immunotherapy (OIT) is a treatment in which ingestion of a small amount of a food allergen on a daily basis can induce a state whereby the food can be eaten with reduced, or no, reaction. This is also known as “desensitization.

The goal of oral immunotherapy is to be able to eat products that contain the allergen without the constant fear of having a reaction.

No. It is not a cure because the food has to be eaten daily to maintain the desensitized state. If the daily ingestion dosage is stopped, most individuals will return to the allergic state and thus lose the desensitized state.

Individuals who are at higher risk of having an allergic reaction during immunotherapy are not good candidates. This includes those with poorly controlled or severe asthma and those who have been hospitalized due to anaphylactic shock from ingestion. Those who have severe eczema or eosinophilic gastrointestinal disease are also not ideal candidates. You and your allergy provider should discuss if you have any of these conditions.

Oral immunotherapy requires several visits to the allergist’s office for escalation (increase) in dosing, and those unable to comply with the frequency of follow up visits are not good candidates.

Those who are unwilling, or unable to inject epinephrine to themselves or their child in the event of anaphylaxis are not good candidates.

Theoretically there is no minimum age, but we prefer patients be at least 4 or 5 years of age to enroll in OIT, for several reasons: 1) some children can “outgrow” their allergy (immunologic tolerance) in the first few years of life; 2) older children are more able to understand and follow staff instructions (such as performing lung function testing); 3) older children are better able to describe their symptoms if any occur; 4) older children are more likely to understand, assent, and cooperate with daily dosing. Age eligibility is therefore a decision made with input from the child, parent, and your allergy provider.

Food allergic patients should schedule a visit with their allergy provider to discuss the benefits and risks of OIT, as relates to their own allergic condition(s). At minimum, patients should have a history consistent with allergic reactivity to an identified food, and also demonstrate specific allergic antibody (IgE) by either skin testing or blood testing to that food, and desire to go through the process of OIT.

Maybe. We would like patients to have allergic antibody (IgE) testing within 6-12 months of starting OIT as a baseline for future comparison. This includes skin and blood testing (IgE ELISA) at minimum, and possibly: allergen component blood testing, and total IgE level.

No. Unlike participating in institutional studies, which often require patients to undergo food challenges to clearly “prove” their allergy and also demonstrate their provocative dose, we do not require this in patients who have a consistent history and positive IgE testing. If the history is in question, however, or if there is a strong possibility that a person may not be allergic (or may have “outgrown” their food allergy), we may offer/recommend a food challenge, because if it is “passed” then OIT may not be necessary.

How many visits to the allergy office are there?

There will be at minimum of 12 visits (typically every-other-week) in the allergy office to achieve the initial target of 300 mg (0.3grams) or more of daily protein ingested. The exact duration and number of visits will vary by individual depending on adjustments in dosage that may need to be made if there are symptoms, or delays or pauses in progression such as for vacations, etc. We are able to individualize and tailor this therapy for safety, comfort and convenience.

The first treatment visit is called the Initial Dose Escalation Day (IDED), and lasts approximately 4 to 6 hours in the allergy office. The goal of the IDED is to progress sequentially through the initial very small doses, to determine the starting dose for home administration.

We will carefully feed a very small amount of the allergenic food by mouth and observe for any reaction. This starting dose is typically less than 1/1000 th of a gram (less than one milligram), which is well below the amount needed to trigger allergic reactions for most food allergic individuals. We will then increase this (still remaining with very small amounts) approximately every 20-30 minutes, up to a set amount, which will be the dose to start daily ingestion thereafter.

As an example, if the allergen is peanut, a starting dose may be 0.0004 grams (0.4 milligrams), and the final dose after 2-3 hours may be 0.006g (6 mg). After the final dose for the day, there is a period of observation for 1-2 hours. If there is no evidence of a reaction, you will be sent home. Thus, the overall visit may last 4-6 hours, but could be longer if there are symptoms or a reaction is treated.

The second visit (Day 2) is the day immediately following the IDED visit and will last about 1 ½ hours. To ensure that the once daily dosing is tolerated, you will return to the clinic to have the first administration of that daily dose (the highest amount tolerated from the IDED the day before) given to you by the allergy staff. After being observed for approximately 60 minutes, you will be sent home with instructions on how to do subsequent daily doses of this same amount, at home, and will be provided the food to do so.

The day following the second visit, you should be able to start taking doses at home. This will be the same amount that was shown to be tolerated in the clinic, the day before. You will continue home dosing, once daily, for approximately 2 weeks before returning to the clinic for consideration of escalating (increasing) the dose.

No. Dose increases need to be performed under close medical observation, and will only be done in the allergy clinic, where rapid assessment and treatment of any symptoms or potential reactions can occur.

The allergy clinic provides the food to be used in dosing oral immunotherapy, at least until approximately 300 mg of daily ingested food is reached. In the first part of the escalation, food protein is usually provided as a solution in a bottle, since solutions can offer more consistency particularly in administering mall doses. As the dose increases, food may be later provided as flours, dispensed in small single-serving plastic containers. The food itself, as well as instructions on how to take it, will be provided by the allergy staff.

No, at the present time, there is no additional charge for the preparation and provision of the food used in OIT for our patients who are compliant and progressing through the protocol. The exception is if replacement (or additional doses) are required when our clinic is closed (such as after our regular hours, on weekends, or holidays). In that case you will be responsible for a charge of $75, that cannot be charged to your insurance, for a staff member to be called-in to accommodate the need.

You will continue daily dosing, so please take sufficient supply to last the duration of the trip, with extra in case your return is delayed. Additional doses are available, without charge, during regular office hours.

Call as soon as you know you will need more. If doses need to be shipped to you, you will be responsible for paying shipping and handling fees. Also, if a staff member needs to come in after hours or on a weekend or holiday, there will be an additional charge of $75. None of these fees can be charged to your insurance.

Patients can advance at different rates, but in general, if there are no reactions, and each escalation visit occurs every 2 weeks, it takes approximately 20 weeks to reach the initial target goal of 300 mg of protein ingested daily, and after tolerating this, patients may switch from clinic-provided food to “regular” store-bought food (eg whole peanuts or peanut butter, etc).

Some do. The liquid food solutions do not contain preservatives, so must be kept cold. Many flours, powders, and nuts are stable at room temperature, so refrigeration is not required (but may be recommended to maintain freshness).

The time of day is not important, but the amount of time between doses is important. Doses should be given approximately 24 hours apart. Individual schedules vary, so some individuals will dose in the morning, while others in the afternoon or evening. Doses should not be given closer than 12 hours apart.

  • The individual needs to be monitored for at least 1-2 hours after the dose
  • No significant exercise for 2 hours after the dose
  • Avoid elevating body temperature (hot tub, sauna, hot shower/bath) for 2 hours after the dose
  • Do not take the dose on an empty stomach. Do take it along with a meal or snack.
  • The dose will not be taken if you have a fever ³ 100°F or are vomiting or have diarrhea

Studies have shown that reactions can occur more commonly in these circumstances, but this is not a complete list. You will have a separate home dosing instruction sheet outlining specific situations and adjustments to take (such as if you are ill, but do not have fever or vomiting).

Yes. Taste is personal, so experimenting is fine here. Try mixing the dose with drink powder (eg Kool-Aide, Crystal Light, etc) or juice. You can also mix the dose with foods- semi-solid foods seem to work well such as applesauce, yogurt, chocolate pudding, mashed potato, oatmeal, etc. Try to give the dose in one bite, or otherwise a small amount/volume, to ensure that the entire dose is taken. If the amount gets too large, it will be hard to get it all down. Please avoid using anything that is hot to mix the dose in.

Ideally the doses are given every day, 24 hours apart, with no interruption. But fevers / illnesses, and life circumstances can happen, causing you to miss a dose. Usually, a missed dose can be re-started at home as long as the last dose taken was within 48 hours, as per your home dose instruction sheet.

When the maintenance dose is reached (i.e. no further dose escalations are planned), follow up visits with your allergy provider will be less frequent (approximately every 3-6 months). You will continue to consume the same dose on a daily basis unless otherwise instructed by allergy staff. Follow-up visits may periodically involve repeat skin and/or blood testing. There may also be an option for an oral food challenge visit where a higher dosage of protein may be given (up to 4-5g) to assess for absence of reactivity to these larger amounts.

Studies show that most patients will exhibit symptoms at some point during the oral immunotherapy process, but they are usually mild, and treated successfully with an antihistamine only (eg Zyrtec [cetirizine] or Allegra [fexofenadine]). Reactions more commonly occur during the dose escalation phase (also called the build-up phase), although they can occur at any time during therapy. The most common reactions include an itchy mouth and mild abdominal pain and/or vomiting. A review of oral immunotherapy with peanut conducted in 5 private allergy clinics reported epinephrine use was uncommon (0.2 to 0.7 out of 1000 doses). Although this is reassuring, you or a caregiver should always have readily accessible epinephrine autoinjectors and follow your emergency food action plan.

Individual results will vary, but studies of OIT demonstrate a success rate of >80-90% reaching the maintenance dose, so we expect that most of our patients should reach maintenance dosing.

Once I or my child reaches the maintenance dose, will I have to eat it every day forever?

Maybe not, but for the immediate future, yes. The goal of our protocol is to induce a desensitized state, where you are less reactive or non-reactive when otherwise exposed to that allergen. But that desensitized state needs to be maintained through regular (daily) ingestion of the food, which is the present recommendation. There are, however, some individuals in studies of OIT who after a period of time appear to be able to stop eating the food yet still maintain their state of non-reactivity when later re-challenged with it. The scientific term for this is tolerance. This is an active area of research, to investigate ways to promote tolerance, and markers to possibly predict it. For now, however, until further guidance is available, uninterrupted regular daily ingestion of the food is recommended.

Often yes, but it depends on your insurance. Office visits for escalation dosing are billed as a rapid desensitization procedure (CPT 95180), which is covered by most insurances. You will be given a detailed estimation of charges before we begin OIT, and our billing staff will work diligently with your insurance. Ultimately, however, it is the patient’s responsibility to know and verify coverage with their insurance company, and pay whatever copays, deductibles, or other out-of-pocket costs are not covered.

The initial offering will be for peanut-allergic patients, but plans are in place to soon also offer several tree nuts (i.e. cashew, hazelnut, almond, walnut), cow’s milk, egg, soy, wheat, and sesame.

Eventually, yes, when the other foods are opened up in addition to peanuts, it will be possible to do multiple foods simultaneously.

If you are interested in proceeding with OIT but are not a current patient at Northern Nevada Allergy, schedule a new patient appointment for an evaluation with one of our providers, at (775) 826-4900 and indicate that you are interested in OIT. If you are an existing patient and have had a follow up appointment with us for your food allergy within the last 12 months, you may contact our OIT coordinator at (775) 826-4900, ext 119 and indicate that you are a current food allergy patient interested in OIT, and we will review your records and see what the next steps are for you.

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