Some food allergies treated with oral immunotherapy
Raphael Rochlitz has no desire to eat a peanut butter sandwich.
He doesn't even like the taste of peanuts, but eating a tiny amount of them daily makes a big difference in his life.
The 11-year-old can join his friends for lunch in the cafeteria at Sowers Elementary in Lithia now, instead of being isolated at a table for children with severe food allergies.
He doesn't need to refuse cookies or cupcakes for fear that undetected peanut traces inside them will cause a dangerous allergic reaction.
“Now we don't have to be scared for him anymore,” said his mother, Helena Rochlitz. “He can eat in any restaurant. We don't have to worry about cross contamination.”
That's been the benefit of a severalmonth oral immunotherapy protocol Raphael completed under the direction of Dr. Kathryn Convers, a Lakeland allergist/immunologist.
It didn't cure his peanut allergy, but it desensitized him to peanuts enough that he can tolerate small doses without a bad reaction.
“The primary goal, I always tell parents, is never to use the food freely,” Convers said. “It's safety for the child, to build a bigger safety buffer around them.”
She's one of a limited number of allergy specialists offering that emerging approach to managing food allergies, a sharp contrast to the standard approach of avoiding food to which you're strongly allergic.
Another is Dr. Panida Sriaroon, medical director of the Johns Hopkins All Children's Hospital Food Allergy Clinic in St. Petersburg.
“You're still allergic to the food, but the body's threshold is much higher than before you do the treatment,” Sriaroon said.
“The goal is to reduce the sensitivity to the food and therefore the severity of allergic reactions,”
Oral immunotherapy, OIT for short, is an oral way to desensitize someone who has a severe food allergy.
“We can desensitize up to three foods simultaneously,” said Convers, whose practice is Lakeland Allergy, Asthma and Immunology.
Allergies to eggs, milk, sesame, wheat and tree nuts like cashew, hazelnut and walnut are other food allergies treatable with OIT.
Convers uses her own clinic prepared solutions.
Some nuts are closely related, such as cashews and pistachios or walnuts and pecans. Most patients can reach their OIT goal for both nuts by doing OIT for one of the nuts in a pair, rather than for both.
Peanut and tree nut OIT is being offered to children as young as 9 months old, Convers said.
Treatment starts with a minute amount of peanut flour in distilled water. The dosage increases with each visit, eventually becoming measured portions of crushed or whole peanuts instead of the solution.
“You have to be very cautious about giving the same dose each day,” Convers said.
Caregivers go home with supplies and instructions on drawing proper doses of solution or measuring the exact amount of peanut or other food. The dose increases over about six months, sometimes longer, before someone goes into a maintenance phase.
Another dimension of treatment came in January 2020 when the Food and Drug Administration approved Palforzia, a capsule, for peanut allergy in children ages 4 through 17.
Patients don't swallow the capsule. They open the capsule, which contains a precisely measured amount of peanut to consume.
“Every capsule is very precise,” Sriaroon said. “That is why this is groundbreaking.”
The All Children's Johns Hopkins clinic currently offers Palforzia for peanut treatment and its own clinic-prepared solutions for other food allergies and children too young for Palforzia.
That clinic shares a building with a University of South Florida allergy and immunology clinic. Sriaroon works at both.
Protocols for treatment and clinicprepared solutions, which aren't approved by the FDA, vary widely based on experience and consultations with colleagues also doing OIT.
Convers and Sriaroon credit Dr. Hugh Windom in Sarasota, from whom they got instruction, in spearheading OIT for food allergies in Florida.
Peanut allergy treatment typically gets the most attention because only one in five children outgrow peanut allergies.
About 70 percent outgrow egg and milk allergies, Convers said.
Although OIT reduces risk significantly, continuing caution is needed.
Rochlitz still monitors food packages to check for peanut content.
“If it's made in a facility that also processes peanuts, that is OK,” she said. “But, if it says ‘may contain peanuts,' I avoid those things for him.”
Some people getting OIT find, as Raphael has, they don't like the taste of a food they used to avoid. But, to stay desensitized, they will need to eat small doses of it for the rest of their lives.
Tolerance for three peanuts would be a typical goal, although some who like the taste may strive for more.
“This is not a treatment you can start and stop,” Sriaroon said.
“You take it and just stay on it. If you don't, your body goes back to seeing peanuts, or any food that you are allergic to, as the enemy.”
It requires commitment from caregivers to make sure children take the dosage daily, at about the same time, and avoid activities raising the body temperature for about two hours.
Reactions can occur during the treatment process.
“When they're doing OIT and the buildup, we want them to be in constant contact with us,” said Convers.
Adults also can do OIT, but it's more commonly done with children.
Studies supporting OIT increased in the past few years.
“In 2022, there's no longer a question (whether OIT is viable),” Sriaroon said. “It is more about what else can we do to make OIT more widely available and cover a lot of foods with sustained results.”