A safe and simple treatment of food allergy using real food
Published online: May 15, 2024
Over the past decade, research studies have successfully desensitized food allergy patients by slowly giving them increasing amounts of the food either orally (oral immunotherapy, OIT) or under the tongue (sublingual immunotherapy, SLIT). With continued ‘dosing’ of the food, the patients are protected if they encounter small to moderate amounts of the food in their diet. OIT has been particularly effective in children under 5 years old. Older children and adults can do well, but they will have more allergic reactions to the treatment that require epinephrine than they did with simple avoidance of the food. There is only one FDA approved commercial product for OIT and currently none for SLIT, and “real food” is often used for OIT by practicing allergists. SLIT offers a much safer means of reducing allergy, but due to the cost of using food extract made for skin testing in the allergist’s office, few patients are offered this treatment, which is not FDA approved.
An article by Windom et al. in The Journal of Allergy and Clinical Immunology: In Practice evaluates the safety of using various “real” foods for SLIT. This Sarasota, Florida study looked at 50 food allergy patients ranging from 5-50 years old, 15 of which had failed OIT. The first group of patients went through a 7 visit build up schedule to their top dose of 0.1-0.5 ml of liquid food placed under the tongue and held for 2 minutes (for reference, a teaspoon is 5 ml). These patients did not experience reactions, so the next 30 patients built up in only 4 visits. They used store bought milk, egg white liquid, tree nut milk (cashew, walnut, and hazelnut), and sunflower milk. Without a readily available liquid form of peanut, sesame, or wheat, patients allergic to these foods were given a bottle of diluted flour solution prepared in the office. A dozen patients went through an exercise challenge before and after dosing to see if it was necessary to restrict exercise around dosing. Patients were followed for a median of 23 weeks as they continued daily sublingual dosing of their food(s) at home.
Food OIT has used real food in the treatment of tens of thousands of patients in the US and abroad. This article by Windom et al. is the first to show real food can be safely used in food SLIT. None of the patients reacted on the first day of treatment, suggesting that an even shorter build up schedule may be possible. Over half of the patients (56%) were treated with a single food, the rest with 2-4 foods, each one given in sequence after the prior one. None of the 12 patients reacted to their maintenance dose despite exercising before and after dosing. This is unlike OIT, where the standard approach is to recommend no exercise for 30 minutes before dosing and a 2-hour rest period after dosing. No epinephrine was used at any stage in any patient. With further research on safety and efficacy, people with food allergy may have a new, simple, safe, and inexpensive option to overcome their fear of eating.
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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