Bypassing OIT buildup with SLIT: a safer treatment for higher-risk food allergy
Published: February 27, 2024
Although oral immunotherapy (OIT) has been shown to be very safe in preschool-aged children, there is a higher risk of severe reactions and epinephrine use in older children and adolescents. In addition to safety concerns, there are other practical limitations of OIT, including exercise restrictions after dosing, which make long-term adherence difficult for older children and adolescents in particular. Because of its favorable safety profile and fewer restrictions on daily life, sublingual immunotherapy (SLIT) has been proposed as an alternative treatment option for those in whom OIT may be of higher risk—older children, adolescents, and those with a history of severe reactions.
In a recently published study in The Journal of Allergy and Clinical Immunology: In Practice, Soller et al. sought to describe the safety of real-world multi-food SLIT in higher-risk participants aged 4-18 years old, and the effectiveness of bypassing OIT buildup with an initial phase of SLIT. Fresh food solutions were used for SLIT. Participants increased their dose up to 2mg to 4mg protein SLIT maintenance over the course of 3-5 visits under nurse supervision. After 1-2 years of daily SLIT maintenance, patients were offered a low-dose oral food challenge to 300mg protein (for example, 1-2 peanuts) to each food with the goal of bypassing OIT buildup.
A total of 188 participants (median age 11 years old) with higher-risk features were enrolled in SLIT, the majority to multiple foods. Almost all participants completed their SLIT buildup, with only 8% dropping out. Nearly all participants experienced symptoms during buildup (93.1%), but most symptoms were mild and only one (0.6%) had a moderate reaction. Four participants received epinephrine (2.1%) for mild to moderate reactions, and none experienced severe reactions. A subset of 20 participants had 50 low-dose oral food challenges (OFCs) to 300mg protein and 35 (70%) OFCs were successful, thereby bypassing OIT buildup. This study highlights that real-world SLIT using grocery store products appears safe for moderate to severe food allergy in older children and adolescents, with very few reactions receiving epinephrine and no severe reactions. Additionally, the data show that 2 years of SLIT maintenance therapy is an effective way to bypass the buildup phase of OIT, which is often associated with significant symptoms in older children and adolescents, decreasing health care resource utilization.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.
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