Ep. 229: International Oral Immunotherapy Guidelines

Not long ago, 36 allergy experts worldwide came together to develop a consensus on preparing their patients for Oral Immunotherapy, also known as OIT. We’re sitting down with FAACT’s Medical Advisory Board Member, Dr. Katherine Anagnostou, one of the 36 allergy experts collaborating in the Preparing Patients for Oral Immunotherapy (PPOINT) consensus. 

Resources to keep you in the know:

• Preparing Patients for Oral Immunotherapy (PPOINT): international Delphi consensus for procedural preparation and consent - Journal of Allergy and Clinical Immunology

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Transcript

Caroline: Welcome to FAACT's Roundtable, a podcast dedicated to navigating life with food allergies across the lifespan. Presented in a welcoming format with interviews and open discussions, each episode will explore a specific topic, leaving you with the facts to know or use.

Information presented via this podcast is educational and not intended to provide individual medical advice. Please consult with your personal board certified allergist or healthcare providers for advice specific to your situation.

Hi everyone, I'm Caroline Moassessiand I am your host for FAACT's Roundtable podcast. I am a food allergy parent and advocate and the founder of the Grateful Foodie Blog.

And I am FAACT's Vice President of Community Relations.

Not long ago, 36 allergy experts from around the world came together to develop a consensus on how to prepare their patients for oral immunotherapy, also known as OIT. We're sitting down with FACTS medical advisory board member, Dr.

Katherine Anagnostou, who is one of the 36 allergy experts collaborating in preparing the patients for oral immunotherapy consensus.

Welcome, Dr. Anagnostou, to our podcast. We are so excited to have you here today. This is a really important topic and this is a very exciting panel. This is something so very new to us.

So we're so excited for today. So welcome.

Dr. Anagnostou: Thank you so much for having me. I look forward to today's conversation.

Caroline: So now let's just jump right in and let's just start out with a conversation with a little bit of your background. And then what is this panel? What is the formal name?

Dr. Anagnostou: Of course. So in terms of my background, I'm a professor, pediatrics, in the Allergy and Immunology division at Texas Children's Hospital and Baylor College of Medicine. I have a tremendous interest in food allergy, pretty much all aspects of food allergy, including prevention and therapies, and also anaphylaxis.

And I lead quite a number of research projects in this area as principal investigator.

So you asked me about the panel. This was work that was performed by not just myself, but a very large panel of 36 allergy experts, pretty much from all over the world, different geographical areas.

We all got together and we wanted to develop a consensus on how we prepare our patients for oral immunotherapy. So this is the work that I will be discussing today when we talk about preparing patients for oral immunotherapy, what they need to know, what they should be looking out for when they have a consultation with their allergist and some basic,

let's say, information about this therapy.

Caroline: Fantastic. Thank you for that. Very clear explanation. And thank you so much for being part of our allergy community and doing this amazing research and pushing the dial forward. We really appreciate it.

Appreciate you doing that for us. So thank you.

Dr. Anagnostou: It's my pleasure.

Caroline: Wonderful. So now we're just going to jump right into the questions. What are some of the general considerations for counseling patients and families on OIT?

Dr. Anagnostou: Of course. So I will start by saying how we as physicians approach this process. But from the patient's perspective, this is probably what they should be expecting when they have a consultation about oral immunotherapy with their allergies.

So one of the first things that do is we discuss the steps of the oral immunotherapy process. So what does this involve in terms of visits and in terms of time commitment from the patient and the family?

We also discuss the fact that oral immunotherapy has many benefits, but it is not a cure. So it doesn't make the allergy disappear or go away. It is a therapy.

We talk about the fact that oral immunotherapy will likely be lifelong. This is not a quick fix. This is more of a marathon rather than a sprint. And we also discuss the natural history of food allergies without oral immunotherapy.

So what would happen to the patient's food allergies if they don't take on any therapy? And of course, what is the potential for the therapy to impact the natural history of food allergy?

So we go both ways, and we present,

let's say, both routes so that patients know what the alternatives are. Another important part of our initial conversation involves what goals the patient and the family have in terms of pursuing this therapy.

So this is a little bit of homework that families can do on their own before actually coming to the visits. They need to have a think about what they're really wanting to achieve from oral immunotherapy.

And what I mean by that is, do they want their child to be protected from accidental exposures? Do they want to reduce the risk of having enough laxus? Do they want the child to be eating increasing amounts of the allergenic food?

There are a lot of things that come in here and they will vary from family to family, but this is something that they can think of before coming to the visit so they have some of this ready.

Caroline: I think that's so critical to be prepared in the sense of what the conversation's going to be like and just to get your mind around it. I think that's so critical.

And so now, can you describe Some patient and family specific factors, factors that need to be addressed before and during oit. You just mentioned thinking ahead about the goals.

Dr. Anagnostou: Yes, this is really important. So from the medical perspective, we're looking at comorbidities. So food allergic patients often have other allergic conditions, such as asthma, allergic rhinitis, atopic dermatitis, we call all of these atopic comorbidities.

Patients may also have chronic urticaria. We, we see that as well. Now, all of these comorbidities need to be well before embarking on oral immunotherapy. What that means is that they cannot be constant exacerbations.

We need to have a good level of control. For example, for asthma, if asthma is a problem, the patient needs to be on the appropriate treatment, inhaler treatment, to make sure that this is under good control.

The reason for that is that if these comorbidities are not well controlled, then the process becomes very difficult with lots of stops, discontinuations, restarts, and it can also present risks to the patient.

That's a very important step that we discuss with families.

Another slightly different step that we need to discuss are any baseline symptoms from the gastrointestinal system. We know that abdominal pain, for example, is quite common, especially in young children.

A lot of times it is completely benign. Other times there may be a cause behind it, because oral immunotherapy is an oral therapy and it has the potential to cause mild abdominal pain as a side effect of the treatment.

We need to make sure that this is not a problem at baseline. Otherwise things again become very confusing. And if the child starts complaining of tummy ache, we won't know if this is the baseline state of this is something that is coming from the therapy.

These are mostly in relation to a medical assessment. But as you very well pointed out, we also discuss the goals that the family has and we address the family logistics because this is a very important part of this successful therapy.

Because if the family, for example, is incredibly busy and cannot make the appointments as needed, or they just don't have time, this can affect compliance and adherence with the treatment.

And it can cause various issues. In addition to that, there are certain practicalities in terms of administering the dose, having adult supervision for a couple of hours after the child having the dose.

So again, these are things that need to be discussed because although the process obviously involves the patient, it has an effect on, on the entire family.

Caroline: Oh, it's a commitment. I mean, definitely a commitment because it impacts work schedules and vacations and all sorts of things. So that's really something. Yeah, that's something to definitely look at.

So now, what are the main indications for initiating oit?

Dr. Anagnostou: The first main indication is obviously having a food allergy. And I have to stress that this has to be an immediate type food allergy, what we call an IG mediated food food allergy.

This is a procedure that is being studied for these type of food allergies.

We use it for both single food allergy, for example, a patient that has milk allergy, but also for patients with multiple food allergies. So it can be used in both of these situations.

Other things that we look at in terms of indications are patients that are unlikely to outgrow their food allergy. If someone has, let's say, egg allergy and everything seems like the patient is slowly growing out of it, then we may say just wait a little bit longer before considering therapy,

because if your food allergy is going to become outgrown on its own, then you probably don't need it. We're looking at how food allergy affects quality of life. That's another important thing.

When considering therapy, we look at previous type of reactions, including previous anaphylaxis, and we're looking at any other kind of burden that food allergy poses on patients and families, such as, for example, nutritional burden, unsuccessful food avoidance, multiple previous accidental exposures,

as well as anxiety in relation to accidental exposures. The goals of therapy come in here, too. We will ask the patients if they are willing to tolerate higher exposure without reaction, or if they want to achieve a situation where they would be able to eat almost like a portion of the food on a regular basis.

And again, there's no really right or wrong answer here in terms of patient goals. It's a matter of preference.

Caroline: Thank you. And so now let's look at the other side. What are the main contraindications to initiating oit?

Dr. Anagnostou: The main contraindication is not carrying epinephrine or being unwilling to use epinephrine. This is, I think, the key message that I would like everyone to take away.

We would be starting a therapy that involves the patient being exposed to their food allergen.

We therefore need to be prepared because oral immunotherapy causes allergic reactions, and sometimes in about 10 to 20% of patients on average, this can be, on occasion, anaphylaxis. So we cannot really start this process in anyone who is either unwilling to carry epinephrine or unwilling to use it.

Other contraindications that are more relative contraindications can be things like uncontrolled atopic comorbidities. Like I mentioned before,

uncontrolled asthma is also a no go for this therapy. It has to be well controlled before we embark on oit.

And the same goes for other comorbidities. I say relative contraindications because if somebody has any of these, we don't tell them that they can't do it. We just go into the process of getting them well controlled before actually starting.

Caroline: Thank you so much for bringing up the epinephrine point. I don't think anyone's ever discussed that before. And that is so huge and so important.

Dr. Anagnostou: Yes, I agree. I think it's one of the major sort of commitments that their families are already making. In all fairness, most of the families are well prepared anyway, regardless of whether they will undergo a therapy or not.

But it's more important to stress within.

Caroline: This context, again, very key. Thank you for really putting a big emphasis on that. So now, can you describe the benefits and the risk of OIT in general?

Dr. Anagnostou: Yes, there is always a balance rate. Whenever someone is considering taking on any type of therapy, it's important to look at both sort of sides. So in terms of benefits, successful oral immunotherapy will allow food allergic individuals to tolerate a certain amount of their food allergen without problems and without reactions.

And that amount can vary from patient to patient. We generally aim for a level that will protect from accidental exposures. So this is the first benefit. There's a lower risk of reacting to accidental exposures, the food allergen after successful oral immunotherapy.

We also know from research studies that even if allergic reactions do occur, if someone is exposed to, say, a large amount of their food allergen, the allergic reactions tend to be less severe.

Following again, successful oral immunotherapy.

One of the benefits that patients value quite a lot is the ability to ingest foods with precautionary allergen labeling. And I have found that for quite a significant proportion of families, this is a big thing and a big benefit.

So just to summarize it in a quick sentence, with successful oral immunotherapy, the main benefits are lower risk of accidental reaction exposures, less severe allergic reactions if exposures do occur, and ability to ingest foods with precautionary allergen labeling.

Caroline: Thank you so much. It's really important, I think, for us to have this type of conversation with such honesty and matter of factness, so families can really understand it. Because, you know, when we're online, we're hearing so many different stories from different people and they're talking about freedom and then other people are talking about the stresses.

And so I just think that's so critical to talk about all these things. And especially.

Dr. Anagnostou: You're absolutely right. And I think that it's really important to look at it from the patient perspective. And also there's a lot of information out there. There's a lot of misinformation out there as well.

And since you brought up the stresses, that is another benefit actually that I sort of omitted before.

A lot of families see a significant improvement in their daily quality of life because a lot of the anxiety that is connected to having an accidental exposure and experiencing enough blacks is actually settles down or even goes away with successful oit.

I would like to balance out benefits and risks. So I think in terms of risks, what families need to know is that the, the most sort of important risks are the ones associated with allergic reactions during treatment.

Because we're obviously exposing patients to what they're allergic to. A proportion of them will experience allergic reactions. Now the good news is that the majority of those are generally mild or moderate allergic reactions.

A smaller percentage of patients, and I mentioned before, in the research studies it has been shown to be anywhere between 10 to 20%. In real world studies it's actually been shown to be lower.

But regardless, there is a risk for anaphylaxis and severe allergic reactions. And that is something that families should know before embarking on oit.

Caroline: This conversation has just been incredible and I hate to see the end of it, but we are at the end of our time together. So do you have any last thoughts that you would like to share with our listeners?

Dr. Anagnostou: And I guess to wrap up a message from me would be that if you do decide or if you are considering oral immunotherapy for your food allergy, make sure that you find an allergist that is experienced in the process.

Go there prepared with your questions, having thought about your goals and what you're aiming to achieve from the therapy. Get as much information as you need and don't hesitate to ask any kind of question because like you very nicely pointed out, Carolyn, there is a lot of information out there and some of it can be very confusing.

And there is also a lot of misinformation. So you need to know the facts before you do something like this.

Caroline: Now those are excellent words to end by. Thank you for sharing your wisdom and your knowledge and your passion and most importantly, your time with us today. So thank you very much.

Dr. Anagnostou: Thank you so much for having me. I. I really hope that the listeners will find this informative and it will help them make correct decisions about their therapies.

Caroline: I think it's safe to say yes to that. So thank you.

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