Food Allergy Treatment Options: As of February 2021
As treatment options for food allergy are constantly expanding, it's important to stay up-to-date to understand all of your options!
This article discusses all evidence-based treatment options for IgE-mediated anaphylactic food allergy as of February 2021.
The only option besides treatment is avoidance. This involves complete avoidance of the food that the person is allergic to, including all forms of cross-contamination. This consists of reading all labels for food products, typically avoiding anything that "may contain" the food and being vigilant of not coming into contact with the food in any way, shape, or form. It may in some cases result in a difficult experience eating out, traveling, and attending social events.
1. Sublingual Immunotherapy (SLIT)
SLIT is a type of desensitization immunotherapy treatment. It consists of drops or a spray that are placed/sprayed under the tongue daily. The solution contains food antigens (allergenic proteins), and the concentration of antigen varies on where/who you get the SLIT from.
SLIT has two main uses, (1) in the treatment of pollen food allergy (referred to in the past as oral allergy syndrome), and (2) as a low-dose desensitization therapy for specific food allergies.
Pollen food allergy is when a patient clinically reacts to foods, typically fruits, vegetables, herbs, spices, and nuts, due to cross-reactivity with environmental allergens. It is a form of secondary sensitization, rather than primary sensitization, but can still result in systemic reactions such as anaphylaxis and life-threatening symptoms. The goal is to use SLIT to desensitize the patient to their environmental allergens, which in turn, will help them tolerate the foods they react to.
SLIT can also be used for a specific food allergy, such as peanut or egg. The method involves administering a very tiny dose of allergenic proteins to the patient with the goal of desensitization to the protein. SLIT is typically considered safe as the dose is extremely low. Because of this though, it can take years before a patient is desensitized, and the degree of desensitization greatly varies.
2. DBV Viaskin Patches
The Viaskin patch currently exists for peanut, milk, and egg only. All three patches are currently only available via clinical trials. So far, although they have been demonstrated to be relatively safe with no anaphylactic reactions reported (although many local reactions reported), it has not been shown to be very effective.
The peanut patch is available via clinical trial for all ages, while the milk patch is only available for ages 2-17. As for the egg patch, it is still in the pre-clinical phase.
3. Palforzia Peanut Pill
The Palforzia Peanut Pill by Aimmune Therapeutics is currently the only FDA approved treatment for food allergy. It only treats peanut allergy (it is not available for any other foods) and is only approved for ages 4-17.
It consists of specific doses of peanut flour put into capsules that are meant to be broken and mixed into food such as applesauce. The peanut dose is taken daily, with doses slowly increasing over time. It is a standardized protocol, thus dosage amounts and updoses are limited in terms of flexibility.
The end dosage is 300mg of peanut protein which is equivalent to one full peanut. This immunotherapy option has the end goal of lessening the severity of allergic reaction symptoms if a patient accidentally comes into contact with peanut.
4. Oral Immunotherapy (OIT)
OIT is a desensitization immunotherapy treatment. The concept of desensitization has been around for hundreds of years, and desensitization to food allergies dates back all the way to the early 1900s.
This process consists of eating small doses of a specific food and slowly increasing that amount over time. The starting dose is typically the largest amount of the food that the patient can tolerate. OIT can be done with any food. The end goal of OIT ranges from safety from cross-contamination all the way to free eating the food.
The time it takes to reach the end goal also widely varies. It is typically considered very effective, although it does come with risks such as anaphylaxis or the exacerbation of other allergic diseases such as eosinophilic esophagitis (EoE).
OIT can be done in various ways. The first option is to do it through a clinical trial. This option eliminates flexibility and personalization, as clinical trials typically have standard protocols. OIT can also be done privately, which offers the highest amount of flexibility and personalization to the patient. When done privately, it may be done together with the addition of Omalizumab (Xolair injection), or probiotic supplementation, depending on the clinic.
During private practice OIT, it takes an average of 6 months to over one year for each food, but again, this widely varies. Patients can usually choose to treat only certain foods and not others. In the United States, Stanford University in California currently runs the largest and most effective form of OIT. There are various OIT centers located worldwide such as in Canada and Israel.
Allergists who offer OIT have different restrictions. Although some offer the treatment to all ages and all food allergies, others only treat specific foods and only specific age groups. Furthermore, not all allergists accept patients with comorbid conditions such as asthma or EoE.
5. Tolerance Induction Program (TIP)
TIP is an immunotherapy treatment based on protein cross-matching. All foods contain multiple allergenic proteins that cross-react with each other. Rather than desensitizing a patient to a protein via exposure such as in OIT, this immunotherapy primes the immune system using similar proteins to the ones which they allergic to in order to guide the immune system to recognize all allergenic food proteins as harmless rather than harmful.
TIP can also treat all food allergies such as OIT, but due to the protein cross-matching method, the patient does not get to choose which foods they want to treat and in what order such as in OIT. The treatment is done in a very specific order of foods with only one end goal: to eat all foods in unlimited amounts. This is known as sustained unresponsiveness to food proteins.
TIP is arguably the safest and most effective treatment due to the intricate and advanced protein cross-matching method used, with a higher success rate than OIT and a lower anaphylactic reaction rate than OIT. It does still hold a similar risk for the exacerbation of eosinophilic esophagitis (EoE).
The Tolerance Induction Program is currently available to patients up to the age of 21 years old and accepts patients with any comorbid condition. It is only offered at the Southern California Food Allergy Institute in Long Beach, California.
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