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Dr. Alice Hoyt welcomes Dr. Tom Chacko, a board-certified allergist from Atlanta, to dive into the complexities of food allergies, focusing on oral immunotherapy (OIT) and sublingual immunotherapy (SLIT). They discuss Dr. Chacko's journey into the field, the importance of whole foods in treatment, and collaborative efforts within the FAST network. The conversation also addresses the need for patient-centric care in allergy treatment.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 1 (00:05):
Hello and welcome to Food Allergy and your Kiddo.
I am your host, dr Alice Hoyt,over the moon, excited to be
joined today by Dr Tom Chaco, anamazing board-certified
allergist out of Atlanta,georgia.
And Dr Chaco and I have crossedpaths, most recently at the big
(00:25):
national OIT conference inDallas, which really, as we'll
talk about some, has become justthe place to go if you are an
allergist who is either wantingto get started doing oral
immunotherapy or you're well inthe weeds of it.
I mean, it's just, it's anamazing experience and an
amazing conference, and so Ialso follow Dr Chaco on social
(00:48):
and I love Tom.
Okay, I'm gonna start talkingto you now.
I love your, I love, I loveyour post.
I love how you keep it so real.
You're really trying to sharegood, evidence-based information
, care, just what's going on inyour office so that so many
families can see what a goodfood allergy journey can look
(01:08):
like.
So I'm so excited.
Thank you for joining us today.
Speaker 2 (01:13):
I am excited to be here, alice.
You're great and I think we'reon the same page.
No, we're on the same page.
We're just trying to educatepeople.
You said just keep this talkreal, like me.
And you are just chatting, justvirtually chatting, so I'm
happy to be here.
Speaker 1 (01:26):
Well, awesome.
So I think what I want to startwith is really just asking you
how did you find yourself inthis part of your career with
such a great focus on foodallergy?
Speaker 2 (01:41):
So I probably started , probably 2014, 2015.
And honestly, not on purpose,it was Hugh Wyndham.
Dr Wyndham, who's one of theOGs, the godfathers in food
allergies, and he's very ethical, very by the books.
He was my mentor, one of myattendings in fellowship.
Oh my gosh, I didn't know that.
Yeah, yeah, yeah, it's a weirdbanter, but he's my attending.
I love that.
(02:01):
He's been on the podcast.
Yeah, oh, he's great and youcan tell he's great.
And he sent me someone that wastraveling from Atlanta to Tampa
to get treatment for peanutallergy 2014,.
No, maybe 2013.
I don't know.
And I'm like Hugh, what are youdoing?
This is kooky.
And then he's like Tom, itreally works, it's good.
And I trusted him.
And then he was the one and itgame changed.
(02:24):
It was a game changer for thatfamily.
And then I started learningabout it.
I started reading the articlesI presented at Emory Journal
Club.
I was like learning and I waslike, if he does it, yeah.
And then eventually I was likeall right, let me start dabbling
it.
And then I was like this seemslike it works and this was
before Palforzia and soPalforzia, but all the data was
(02:45):
out there using peanut flour.
The company was actually out ofGeorgia Bird Flour, peanut
Flour and I was like we couldjust follow this and I probably
started with peanut, probably2015-ish.
Speaker 1 (02:58):
I love that.
And wait, let me pause you fora second.
If you're joining us, you're aparent and you're somewhat new
to the food allergy space,especially when it comes to
peanut allergy.
There's currently oneFDA-approved product to treat
specifically peanut allergy.
There's two FDA-approvedproducts to treat food allergies
(03:20):
.
One is omalizumab or Zoller.
It's an injectable medicationthat decreases the likelihood
that someone will haveanaphylaxis if they accidentally
ingest their allergen.
And then there's Palforzia,which is defatted peanut flour,
which is what Tom is referringto, regarding there only being
one, or what Palforzia is, andit was before Palforzia, because
(03:44):
Palforzia came out I believe itwas February of 2020 is when it
got its FDA approval right.
It was like right before COVID.
Speaker 2 (03:53):
Honestly, I don't know, because it was just peanut
flour, can I guess?
Speaker 1 (03:56):
why you don't know.
Yeah, because I'm like Becauseyou've already been using other
real peanut food that a parentcan go to the grocery store to
get, yeah, years prior.
Speaker 2 (04:11):
So I don't know, I haven't used it and I don't
think now I think it's beenfalling out of flavor.
To be quite honest, I thinkit's now like everyone kind of
knows, like what is?
The emperor is wearing noclothes.
Whatever they say, they're justpeanut flour.
Come on man, Come on man, Stoptalking about this.
Speaker 1 (04:22):
Yes, so I actually have some thoughts on Palforzia,
though, and I did a blog postwhere I think I wrote the nine
reasons Palforzia has not donewell, and one of the reasons is
this is anecdotal.
So if you listen to thispodcast regularly, you know I
really like to live in evidence.
I like to gain as muchinformation as I can from
(04:44):
evidence, but at the end of theday, some of this is coming from
what are we seeing?
And a lot of evidence-basedmedicine comes from somebody
making an observation and thendoing some science to figure out
what's going on.
And so, with it being defattedpeanut flour and some of my
colleagues who have, kind oflike, dipped their toes into OIT
(05:06):
by just doing Palforzia,they're getting a lot of belly
aches in their kids.
Now, historically, I have donepeanut butter for OIT since I
started in either 2018 or 2019.
I had one kiddo earlier thanthat, but I've done peanut
butter and I think peanut butteris great because it hangs out
in the mouth.
(05:27):
It's sticky.
We'll talk some about slit andhow we think all this immune
stuff actually works, but Ithink the most whole foods we
can use for immunotherapy thebetter.
So I don't really likedefatting it.
I actually think it might messwith the digestion and cause
more of the upset tummy.
What say you, tom?
Speaker 2 (05:49):
So I would say it's your podcast, but I'm allowed to
disagree.
Speaker 1 (05:54):
I love it.
Yes, bring it on.
Yeah cool, so I would say Iron,sharpens, iron, yeah, yeah,
yeah.
Speaker 2 (06:00):
Well, I think the rookies that are doing the OIT
and saying they're having issueswith Palforzer because probably
the people who are doingPalforzers aren't doing it too
much but I think what they'redoing is they're probably trying
to get, they're probably tryingto do it on the really allergic
kids which I believe.
So their IgE is greater than100, greater than 50.
And they're probably aiming atthe high doses and the data that
(06:24):
you do.
Yeah, you're going to getproblems, that's true.
Speaker 1 (06:26):
So that's so interesting because I feel like
I hear from families that I'veheard multiple times and I see
on social I totally lurk in someof the groups that, oh, I've
been told that my child is tooallergic for OIT.
Speaker 2 (06:40):
Please, so okay.
Speaker 1 (06:42):
All you go, find some All right.
Speaker 2 (06:45):
This is what I'm going to say is what are you
calling OIT?
Because that's what the messagecomes out as, and you're going
to see a post on this, because Isay I just did a post on how
spicy do you like your chickencurry?
Because all chicken curry isnot the same and all OIT is not
the same, and I think that'simportant to say that Everyone
wants to trend this.
Oit is not the same and I thinkthat's important to say that
everyone wants to trend this OITworld Like it's one big thing,
(07:08):
like OIT is one thing.
That's not how it is.
Just like.
All right, this is for patients.
But I'm going to talk to otherallergists.
We know there's a difference inreaction rate between the red
vial and the green vial.
Right, there's a difference inreaction rate of food
introduction.
Call it oit, call it.
So.
When you're aiming at 300milligrams of protein, which
(07:29):
palforzia did, which they did totry to get approved zolair,
you're going to get more errorsor more issues.
I should say what if you'reaiming at 50?
What if you're aiming at five?
So that's a long answer tothere is no number that you
can't do.
Food introduction we just mighthave different goals.
Speaker 1 (07:48):
And I'm going to connect the dots here for our
listeners.
So when he's talking about vialshe's talking about when we do
allergy shots we start with likefor pollen allergy, for cat
allergy, things like that.
We do allergy shots and we havefor decades small amounts
injected over a long period oftime teaches the body to
tolerate those allergens.
But what you're getting at hereabout not necessarily pushing
(08:10):
the dose so high is maybe twothings One is being on a low
dose for a long time can be veryhelpful, and two in growing
tolerance, meaning getting kidsto freely eating, possibly not
always, but possibly Highly,possibly, highly, possibly.
But two, getting kids to whatreally should be everybody's at
(08:35):
least everybody's goal regardingany immunotherapy of decreasing
the likelihood of a severeallergic reaction I talk about.
There can be two goals with OITreally.
One is let's get kids bite safe, meaning if they accidentally
eat a bite of their allergen,they won't have a severe
allergic reaction, hopefully noreaction.
But then that other goal that'salways in the back of my head,
(08:56):
regardless of the age,regardless of what the IGE
number is, is let's see if wecan drive this bad boy home and
get to freely eating and overtime get this thing in the
rearview mirror.
Speaker 2 (09:10):
Yep, so I agree, and it all depends on the patient,
it depends on the case, itdepends on the numbers.
We're starting with theirsensitivity IgE numbers talking
about blood work IgE numbers.
Ige numbers talking about bloodwork, ige numbers, and so I
don't, I don't.
I on my post, and with bothpatients and allergists and
(09:30):
doctors and providers, I wantthem to know when you label OIT
as one big thing, you don't.
That's not the details, thedevil's in the details.
And so what, alice, when youasked me, hey, my numbers are
too high for OIT, I'm like areyou too high for 5 milligrams,
10 milligrams?
And we know you mentioned theFAST meeting.
Right, we've been doing thatfor what?
(09:51):
Seven, eight years and we usedto aim at super high doses.
Now we know you go low and slow.
You get there.
You know, maybe what is it?
Tortoise in the hair?
Maybe don't go that, don't bethat fast.
Buddy.
Us in the hair, maybe don't gothat, don't be that fast buddy,
slow and steady, and it's not arace.
Yeah, so I, I and I think whenwe talk about this we're going
to hear a lot of agendas ofpeople like giving a negative
(10:15):
point on OIT because they weregoing so high and these reaction
rates and so.
So that's when you said, hey,that going back to the Balfour's
year thing, I think justdepends on the case and it was
somewhat immediately available.
Then COVID happened.
Speaker 1 (10:30):
So I don't think anybody was doing a whole lot of
starting Palforzia then, but itwas 2020.
(10:53):
People have been doing OIT foryears before that.
So people who were already veryengaged allergists, who were
already very engaged in thespace, had already been using
products that they were verycomfortable with, that they
could purchase, that theirfamilies could, their you know,
their patient families couldpurchase at the grocery store.
Whatever the case may be, and Imean I'll I agree that as a
(11:17):
doctor, like if I getcomfortable with something, it
it's going to take a lot ofevidence to move me over into a
different camp.
And I know there's some argumentthat oh well, if you're not
using the Palforzia capsule,then do you really know how much
dose they're getting?
And do you really trustfamilies to how dramatically I'm
(11:38):
saying this do you really trustfamilies to measure their
allergen correctly, measuretheir allergen correctly?
And my response is teaspoons,tiny teaspoons, milliliter
syringes.
They're all appropriatelymeasured.
The whole point of OIT is to below and slow below the reaction
threshold.
And If I don't trust a familyto give a child the correct dose
(12:03):
of Tylenol, then maybe I wouldnot trust them to give their
correct dose of peanut butter,but most families can do that,
and so we have to trust ourfamilies to work with them.
And so I think it's really kindof insulting to families when
we're like, oh well, we can'ttrust you to measure this, this
(12:25):
has to go through big pharma,you can't measure this.
Wow, this is getting reallyspicy today, tom.
Speaker 2 (12:31):
Well, also right.
Part of it is because there's alot of you are our meeting and
it is what it is.
Right, Like there's a lot offinancial incentive to tell
people that this is somethingdifferent.
Right, Like I've gotten, nowthat I've done social media, I
probably get a call or a DM aweek, maybe more, from
(12:53):
allergists trying to learn aboutthis, but we're not getting
told because, like, they won'tlet this will not go on our
academy or any big meeting.
You know that right, Becausethere's big sponsorship to make
us think that certain meeting.
You know that right, Becausethere's big sponsorship to make
us think that certain things aredifferent than others.
Right, and so I don't.
It's not all, it's just who'sfunding that narrative.
(13:17):
And I've said that numeroustimes.
Speaker 1 (13:18):
Well, ultimately the way studies get funded is
there's a drug that couldpotentially help treat somebody
and that drug is made by acompany and in order for that
company to make the drug, I meanthey do have to raise money.
Those studies cost so muchmoney.
But I mean you're hitting thenail on the head.
(13:40):
I remember when I was infellowship it was so hard to
even contemplate writing an IRBan institutional review board
application to do a study withsomething like peanut butter or
pasteurized liquid egg white,because it's a food, it's not a
drug.
And the whole concept of usinga food to treat a condition is
very like, very strange toregulators minds, very strange
(14:03):
to regulators' minds.
And when you do follow themoney trail then it is hard to
say, oh well, okay, well, we'rejust going to do all this big
study but then not have some wayto get reimbursed or make money
from it.
Like I get that.
You know what I mean.
But at the end of the day, thisis where healthcare is not
(14:25):
traditional business.
And look, I'm all aboutcapitalism.
This is not a political podcast.
I think capitalism done welldoes serve our communities.
Greedy capitalism is somethingcompletely different.
It's not what I'm talking abouthere.
At the end of the day,healthcare is different,
different and health care has tobe treated differently.
(14:45):
We could go on and on abouthealth insurance and all of
those things right now, but it'sa challenging situation, I
would say, because we do wantall of this data.
And what I think is sobeautiful, tom, and how we even
got connected, really is becauseof FAST, the Food Allergies
Support Team meeting in Dallas,because of this amazing network
(15:08):
of OIT allergists.
I think what Dr Wasserman saidthis looks like 700 people on
the email list or something likethat, which, compared to how
many kids and adults have foodallergies, is kind of small.
We're still the minority is kindof small.
(15:29):
We're still the minority, yes,we're still the minority, but
it's nice that, how muchinformation we all share.
I mean, I check my email and Iusually have at least two to
three emails from members ofFAST OIT.
We're all like talking aboutdifferent cases.
What we're seeing you know whatwe're seeing with NEFI that's
big on the chain right now Like,do we think it's working as
well as the auto injectors?
(15:50):
What different foods are weusing for different OIT?
Or now with SLIT.
So it's nice to shareinformation.
Healthcare is just, it's such aunique, a unique beast and
that's why I think, at the endof the day, it's so important
for families to be very mindful,be informed, get your
information from from goodresources and that's again why I
(16:13):
love your Instagram, cause it'sit's not sensational, it's not
sensationalized, it's just, it'sjust real.
And have good discussions withyour allergist.
And if you're a parent, you'relistening to this or watching
this on our YouTube and you'relike wait, my allergist hasn't
talked about OIT at all.
Then ask your allergist hey,what do you think about OIT for
(16:35):
my kiddo with an anaphylacticfood allergy?
And ask if they don't do it,then ask okay, well, who do you
know that does do it?
It then ask okay, well, who doyou know that does do it?
And I would like to get anopinion from them, because it is
high time, to your pointearlier, that more patients know
about this option.
Speaker 2 (16:56):
I would argue this, and I don't.
First of all, my colleagues, mybuddies, my guy that I trained
with they don't offer it.
So I want to be very clearbecause your allergist doesn't
offer it doesn't mean they'rebad doctors.
It just might not be theirthing and so that's okay.
Just make sure you find someonewho is their thing.
So that's why I'm like ask themand they might just say, hey,
(17:17):
our academies don't recommend it.
Well, there's reasons why ouracademies don't recommend it.
Our academies, we didn't gettrained.
I don't think they don't.
Speaker 1 (17:23):
Not, I don't think they don't not recommend it
though.
Speaker 2 (17:28):
But I don't think if they recommended it, we wouldn't
be having a separate FASTmeeting.
We'd be having a session on howto do OIT and we wouldn't be
having.
I like the patch test sessions.
I like the rhinoscopy sessions.
There should be a foodintroduction.
I've actually went out to them.
I emailed them and said can Ido my talk?
And they're like we have.
And it was actually one of thefolks does OIT, but she's like
(17:51):
we're kind of regulated on howwe do some of these talks.
Speaker 1 (17:55):
So I will say some of that is probably to obtain
continuing medical educationcredits and so to get that CME
hours, which a lot of us go tomeetings to obtain the CME hours
and the FAST.
We don't even mess with thatbecause, you're exactly right,
there are regulations there thathave to be followed so that
people can feel good about theeducation that they're receiving
(18:18):
.
I will say the FAST meeting issome of the best, most practical
information.
They're the best meetings handsdown I've ever attended.
Speaker 2 (18:29):
But then, what do you think?
Speaker 1 (18:30):
about and I get no CME from it.
Speaker 2 (18:32):
No, we get no FAST meeting is the best.
You know.
I spend a lot of.
I spend hours, you know, doinglectures.
You spend hours, hourspreparing for it.
Right, I pay for it too.
I don't give a, I pay.
It's not sponsored.
I pay my hotel, which I love.
I would never not, because Ithink it's very sincere, it's
(18:52):
the most cleanest.
We're just trying to good work.
Speaker 1 (18:54):
Yeah, so I agree with you.
It's genuine.
You know, the information beingpresented is just like
unfiltered.
Speaker 2 (19:02):
Unfiltered, and people with a passion that want
to teach, like we lose clinic,like we just we just think it
should be out there.
We think I know, I think wejust sorry, I just want a big
thunder.
Yeah, um bolt, I don't evenknow that, so, um, no, but I
think, I think it's I, you know,and now it's us, the guys who
have more experience, justgiving back.
(19:22):
You know, the younger guys, youknow.
Speaker 1 (19:33):
So I love it.
It's on my calendar.
I know it's a great meeting,okay, so I want to move into
Slit, though, and then talk alittle bit about that.
I also love your little peanutpuff approach.
I love Mission Mighty MeatPuffs.
I do some spokesperson workwith them on occasion.
Speaker 2 (19:46):
There's my disclosure .
I just did a podcast with themyesterday, but I'm not a speaker
, I do it for fun.
They live in Atlanta.
Speaker 1 (19:54):
How I got connected to them was my in-laws live in
Atlanta and a few years ago mymother-in-law saw in the local
newspaper this article aboutthem.
She cut it out, brought it toour family beach trip and I was
like, oh my gosh, this isamazing.
So I emailed her, catherine.
I was like, hey, do you want tobe on my podcast?
And it was a lovely episode.
So I love their mission missionreminding me.
(20:15):
I love how they're working sohard to make their products
really good products.
But I really liked how you'redoing some OIT with their
products and I mean it's just soreal world right.
And also how you're thinkingabout SLIT and OIT.
Let's dive into that, sir.
Speaker 2 (20:37):
So let's talk about SLIT.
So SLIT a lot of people aretalking about, and SLIT is
sublingual, where you basicallyput the food allergen under your
tongue and absorb it.
And SLIT is sublingual whereyou basically put the food
allergen under your tongue withan absorber and the thought is
that it lets your body tolerateit.
Right, it's all.
Most of the SLIT data is basedon Edward Kim's data.
Who's out?
Speaker 1 (20:54):
of California.
He's brilliant right.
Yep had him on the podcast.
It was great data.
Speaker 2 (20:59):
It was done very well .
So I don't disagree with hisdata and I don't, but he
mentions it himself and heactually says it.
He did a Canadian podcast wherethere are one to two-year-olds.
Most of the kids were liketwo-ish and they put it under
their tongue.
But I've said it numerous times, they can't hold their potty.
(21:19):
There's no way they're kiddingon this, they are swallowing it.
They're swallowing and hedoesn't.
And he's credible.
He doesn't say that's not thecase, right.
Speaker 1 (21:29):
He's the real deal.
Speaker 2 (21:30):
Yeah, he's the real deal, he's keeping it honest.
So, in my opinion, they'rebasically taking five milligrams
of the protein of peanut,because that's the only one
that's come out.
They'll get an FDA-approvedproduct.
They're working on that andthey're working on tree nut too,
but it's just five milligramsof the protein swallowed and it
(21:50):
works low and slow.
It worked on the kids.
It worked really well.
So I just think it's anotherway of low dose OIT, I think the
caveat is the kids.
Speaker 1 (22:04):
They I have to look back at the paper, but what I
advise my families who are doingSLIT is no food 15 minutes
before, 30 minutes after, if atall possible, Definitely five
minutes before and 15 minutesafter, so that it's literally
just a fairy spit of allergen intheir mouth and that's it.
So just full access there, asopposed to with OIT.
(22:27):
For parents who are listeningand aren't super familiar with
OIT, we like OIT to be dosed ona happy tummy that's how I
describe it not on an emptytummy.
So a lot of times kiddos willstart to eat dinner and take
their dose, or dose with a snack, and that's so that the tummy
isn't just receiving thisrelatively large load of
(22:49):
allergen relatively largecompared to slit.
To put it into perspective, onepeanut has about 300 milligrams
of peanut protein.
So when we're talking aboutfive milligrams, four milligrams
like that is such a smallamount.
That is an amount that a lot ofOIT allergists will start OIT
or maybe a few doses before thenwill start OIT, and that's the
(23:10):
maintenance dose with slit.
When I talk about should we slitor should we OIT with my
families, it's a lot of.
What season of life is thefamily in?
Would they even be able to dothe OIT one hour before, two
hour after, dosing, rest periodof not you know running track,
doing baseball, all the thingsright?
(23:32):
And if they're not, then we'releaning a lot more into slit
because the safety window is alot less and that's very
heterogeneous amongst allergists.
I say 15 minutes before, 30minutes after, but I think some
people are just like whatever,it's such a low dose, it's not
going to cause a problem.
Speaker 2 (23:49):
What are your thoughts on that?
I would say I agree.
So it's interesting because youwere talking about slit on your
baseball players, because yes,I think slits are good, or low
dose OIT, which I would say issimilar are good on your
teenagers or the kids who arebusy and kind of.
The ship sailed.
The IG is already up.
Alice.
You already published the dataon the little ones On the little
(24:11):
ones.
Oh, thank you, yeah, youpublished that right, I've
quoted you like numerous times,like every FAS meeting, I think.
The publication came out in2023 from Cleveland Clinic and I
just reset it Like 22 kids.
They gave them Bomba.
They got them them to 500.
No, we did peanut butter withthese little tiny.
Oh, I got the one.
(24:33):
I did one.
Oh, maybe peanut butter.
I knew it was protein, though500 milligrams of protein was
the end point, and that'sbecause of that, that's my goal.
So sorry, I switched them toBomba.
So with the goal, that's fine,yeah, but with the goal of 500
milligrams of protein.
Speaker 1 (24:48):
So that's how I use that number.
You know why I picked 500milligrams?
No idea.
Because when I started doingthis tiny teaspoon protocol it
was after I came home from aquad AI meeting and I was like I
can't keep telling familiesthere's nothing I can do, like
there's clearly something I cando to help their child with food
allergy.
And my mom had sent me thesevery cute teaspoons, like years
before, because she thought theywere cute.
She thought I would think theywere cute.
(25:09):
So I was reading Brian Vickery'spaper on his preschool OIT and
I was like, well, how can Iconvert this into something
that's like feasible, likepeanut butter, that's normal,
right and very practical?
I'm a simple country doctor.
How can I just make this easyand how can I make it effective?
And when you look at thatVickery paper, he compared kids
who did 300 milligrams of peanutprotein to 3,000 milligrams of
(25:31):
peanut protein.
The kids got to the same amountof tolerance.
They did equally as well,except the higher dose kiddos.
They had more reactions.
I'm like, well, I don't wantreactions, I just want
effectiveness, right.
But I was like 300 milligrams.
Well, I mean, I just wanteffectiveness, right, but I was
like 300 milligrams.
Well, I mean, I just want tomake sure that they're getting a
real dose, and what if there'ssome variation in the dosing?
So why don't we go up to half ateaspoon?
(25:51):
That's about 500, 600milligrams.
That sounds good to me.
Speaker 2 (25:58):
And that's why we did it.
Practical application ofscience.
So I aimed we're saying almostthe same, different ways of
saying the same thing with mybabies.
I try to get them three Bomba,then six Bomba.
I leave them with that About500 milligrams of protein.
Speaker 1 (26:12):
Are you using more Mission Mighty Me than Bomba now
?
Speaker 2 (26:15):
I like my Mission Mighty Me on my tree nut ones.
I do a lot of those for thetree nut ones.
So we were talking about Slitright, and we're trying to get
them to five to 10 mil.
So slit dose is about fivemilligrams of protein, five to
10 milligrams plus or minus.
So teenager comes to me 14 yearold, I have literally three
today that comes to me Peanut at15, cashew not too bad too, it
(26:40):
gets you, gets you.
But so, and I've gotten burnedon this one.
But usually I'll build them upand then I'll put them on one
Mission Mighty Me puff, itdissolves and I'll either send
them on one or two.
So that's my low dose RIT,that's my slit and it's easy,
that is easy Not having torefrigerate, not having to use
(27:01):
glycerin.
And it dissolves.
And you got that five to 10milligrams.
And the problem is if that gets.
I think I'm doing the samething that Edwin Kim's going to
do with his FDA approved slant.
I think it's the same thing,literally so and he's coming out
and they're publishing it.
They're going to try to do itfor Trinod too.
I think we're talking the samething, I know I know.
Speaker 1 (27:24):
But you know, what's so nice about the studies and
the pharmaceutical products isthat, especially like when
Palforzia came out, it put theperiod on the validation of this
works.
You know, it's no longer justin a journal, which I mean to us
being in a journal, it's likeI'm published in a peer reviewed
(27:44):
high impact factor, not pay toplay journal.
Yes, you know, but gettingthrough the FDA is.
We won't go down the rabbithole of FDA right now.
Speaker 2 (27:56):
And I don't deny that .
That's why you need the studiesto prove it, studies to prove
it.
I'm just saying when someone'slike saying oh, I'm doing SLID
or this because thisFDA-approved product will likely
there's multi-millions ofdollars getting this to come out
, I'm just not sure it'sdifferent than one or two Mighty
Me Puffs Right.
Speaker 1 (28:14):
I'm with you.
I'm with you.
I love this conversation.
Okay, I know we're going up ontime.
I could talk to you forever.
Let's get to those socialquestions, because your amazing
team asked for some questions.
So what do we have?
Speaker 2 (28:30):
The big question one I get a lot is why aren't more
allergists or academicinstitutions doing this?
Speaker 1 (28:36):
I have this conversation regularly.
I will say why are not moreinstitutions doing it?
I would say because very rarelyare doctors leading truly
leading institutions.
And if doctors were trulyleading institutions, then there
would be significantly lessbureaucracy to get these types
(28:58):
of protocols approved, where allyou need is to bring in peanut
butter to start to treat achild's medical condition.
There's that.
There's well.
Now we have an FDA-approvedproduct, the Palforzia, the
Zoller.
So these are FDA-approved.
So maybe we, as a biginstitution, maybe we're
supposed to use the FDA-approvedones before we try peanut
(29:19):
butter that's not FDA-approvedLike I've heard that before,
when Palforzia first came out, Iheard that the institution was
not permitting it because theway Palforzia was working I
don't know how it is stillworking, but they would actually
mail it to the patient, which Iknow they do do that some and
the patient would bring in theirdose.
Well, the hospital was notpermitted to give a dose of
(29:43):
something that did not comethrough the pharmacy.
So there is that.
And then there's the trainingbit, and how allergists are
trained is you can be aninternal medicine physician, do
an internal medicine residencyor a pediatrics residency or do
med-ps, which is what I did,which is do both, decide to do
(30:04):
both, but you are applying forall the same allergy spots.
There are not nearly enoughallergists in this country to
take care of all the adult andpediatric allergy patients.
And when you're applying sothose internal medicine and
pediatrics residents, they'reapplying for the same.
It's not like just a pediatricsallergy fellowship or just an
adult.
It's not.
And our board is a separateboard.
The American Board of Allergyand Immunology is separate from
(30:25):
American Board of Pediatrics,american Board of Internal
Medicine, and we are vying fordifferent spots.
So we don't have enoughallergists.
And then in the institutions,because of the multiple factors
I listed I probably forgot somethey're not doing a lot of the
OIT, so then they're not gettingthese fellows which is a
trainee in allergy andimmunology, it's called a fellow
(30:46):
.
They're not getting taught howto do it, so then they're not
coming out of training doing it.
And then you're exactly right,they hear and especially
allergists who have been inpractice for a while they've
heard a lot of the bad thingsabout OIT and not as much of the
good stuff, which again is oneof the reasons I love what
you're doing with your Instagramand I was so happy to have you
(31:07):
on the podcast.
So that's my answer.
What do you say?
Speaker 2 (31:10):
My like five minute answer.
Well, actually you understandthe academic aspect more than I
do.
Like I didn't know about thedistributing it and stuff like
that.
I agree with everything yousaid, but I would caveat that
also pharma's big right Like allthe guys that are publishing
that speak, the leaders at ourmeeting are pharma.
They're great, but they havepharmaceutical sponsored studies
(31:33):
right, and so there's somethingto do like there's some agenda
in that, and so I think thatalso influences a lot of the
training and a lot of likethey're not training, they don't
know and they don't.
I don't like.
Scripps did it, you guys did it, but not many of our leading
(31:54):
institutions in the US, inCanada, they do You're talking
about the US Clinic.
Yeah, cleveland Clinic right.
Speaker 1 (32:00):
That's what I saw.
I'm in my own practice now,since 2021.
Speaker 2 (32:03):
No, no, but at least you're authored on the one that
I posted.
Yeah, I was at Cleveland Clinic.
I love my Cleveland Clinic.
Yeah, yeah, yeah.
Speaker 1 (32:10):
So we had amazing leadership with Dr David Lang
supporting the development ofthe Food Allergy Center of
Excellence at Cleveland Clinicwhen I was there, yeah, but I
still saw the hurdles, thebureaucracy, everything we had
to go through to get to thatpoint and that's why I'm so like
intricately aware of thechallenges.
(32:31):
But because we had thatchampion and Sandy Hong and
these other just like reallygreat people at Cleveland Clinic
and at least when I was therethey were pushing like physician
leadership and at least when Iwas there they were pushing like
physician leadership, we got itto where it needed to be.
You know, and if you don't havethat it makes it really hard
and you're right with the pharmait gets really.
(32:52):
It's tough and you know it'stough to sit in there and we can
all have disclosures, right.
So I mentioned I'm aspokesperson for Mission Mighty
Me Like that's great right.
What else?
Oh, mission mighty me Likethat's great right.
What else?
Oh, I do some consulting withKaleo.
I've stocked Kaleo foreverbecause I think it's a very safe
.
But when I was polling thegroup, you know, talking with
our fast OIT email, you know, Iput that in there like hey, like
(33:15):
I have a disclosure here.
But one of the reasons, like Iwork with Kaleo is because I
believe in their product.
I've seen it work for years,long before I've been a
consultant for them, you know.
But it is to your point.
It's hard to hear like talkafter talk about how great this
drug is or that is, when thereis so much behind it that helps,
(33:38):
you know, put food on someone'stable.
Speaker 2 (33:40):
Yeah, it's hard, like , so I agree with everything you
say, but I do think you havethere's some financial biases
that you have to think andthat's part of the reason why
our bodies are not differentthan the bodies in Canada, you
know, but like, but the dynamicsare right, like that makes
sense.
So I love the Canadian side.
(34:02):
I absolutely love, I love, Ilove those guys there.
Like I don't even know thempersonally, but I love what they
do, they publish awesome stuff.
Speaker 1 (34:10):
Okay, next question.
Speaker 2 (34:12):
I have one this is you kind of asked me this but
extremely elevated total IGE towhatever, whatever food.
What can we do?
Speaker 1 (34:22):
So those are the kids that I'd say need support the
most.
Now, having a high numberdoesn't necessarily mean they're
going to have a more severereaction.
Right, number and severitydon't necessarily correlate, but
likelihood of being allergicdoes correlate, and especially
in these kids where the numbersaren't going down like that's a
total bummer right, where likethere's a baby diagnosed and
(34:42):
it's like, oh well, let's waitand see.
(35:03):
And then they come back a fewyears later and eczema can just
have the body rev up making awhole bunch of immunoglobulin E,
which is the allergic antibody.
But yeah, I mean, I think thehigh numbers, those are the kids
that need support.
Speaker 2 (35:16):
So I would agree with you and you've seen my case.
I'm always very specific ontelling people the numbers, like
on my case, right.
I'm always very specific ontelling people the numbers, like
on my case.
I want people to see thenumbers that are treated.
It's very.
I try to be detailed, maybe toodetailed, but yeah, and it just
depends on the case, right.
So, for example, if thepeanut's greater than 100, I'm
(35:36):
not going to aim for 300milligrams of protein, I might
aim at a lower dose, I might goat the slit, I might go at 10.
I might go at 20, but now let'sswitch that up.
And now let's say it's the milkand the milk is 70.
And I'm like man, but the kidcan't eat milk.
That hurts him every day.
So I'm still going to say Iwould still consider treatment,
but now we just go slower.
It might take me six months toslowly roll that in, but I'm
(35:57):
still aiming to get that kid tofree eat, because milk it's hard
to avoid milk.
It is hard, especially our, ourmilk egg kids, yeah, and so my,
and like my egg ones, I mightnow aim to just get them to eat
in the baked form.
So so, so, cause now I don'twant Joey not being able to get
a birthday cake at someone'shouse you know.
Speaker 1 (36:19):
So a million percent.
So much of this is quality oflife and improving the child's
quality of life and, honestly,the family's quality of life.
You know there's so muchanxiety that goes along with
having a child with food allergy.
If there's something we can doto intervene to make it less
likely that a child's going tohave a severe allergic reaction,
we need to do it.
Speaker 2 (36:39):
Yeah, so so my take on all of that is that options
are there.
Talk to someone who knows andkind of gives you can, can can
walk you through your, your,your choices.
Speaker 1 (36:50):
I love it.
And if you're in Georgia,parent listening, then you
should go see Dr Chaco.
So how many?
You have a lot of offices.
Speaker 2 (37:01):
Yeah, so we're.
We're all around Metro Atlanta,so you have a lot of offices.
Yeah, so we're all around MetroAtlanta, north Atlanta, and
we're happy to help.
We'd be happy to see us, andnot many people, I do think, not
just in Atlanta, but across thecountry most parents are still
hearing that avoidance is theonly option.
Or they might be saying thatdoctor only offers avoidance or
Zolaire, and I think that's mymessage to everyone listening
(37:25):
that those are not your onlyoptions.
Speaker 1 (37:27):
Right, it's great to have those.
Avoidance is always an option.
It's great to have Zolaire as atool in our toolkit.
I appreciate Palforzia, butthere's more.
Speaker 2 (37:38):
Yes, and Allison, I know, not just us, but there's
doctors like us across thecountry, and so I just want you
all to know that there's optionsout there.
Speaker 1 (37:52):
There are options.
I love it, dr Chaco, thank youso much for coming on the
podcast.
You're awesome.
You're welcome back anytimethis was so much fun.
Thanks so much for tuning in.
Remember I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned today.
Like subscribe, share this withyour friends and go to
(38:14):
foodallergyandyourkiddocom,where you can join our
newsletter.
God bless you and God blessyour family.
Hello and welcome to Food Allergy and your Kiddo.
I am your host, dr Alice Hoyt,over the moon, excited to be
joined today by Dr Tom Chaco, anamazing board-certified
allergist out of Atlanta,georgia.
And Dr Chaco and I have crossedpaths, most recently at the big
(00:25):
national OIT conference inDallas, which really, as we'll
talk about some, has become justthe place to go if you are an
allergist who is either wantingto get started doing oral
immunotherapy or you're well inthe weeds of it.
I mean, it's just, it's anamazing experience and an
amazing conference, and so Ialso follow Dr Chaco on social
(00:48):
and I love Tom.
Okay, I'm gonna start talkingto you now.
I love your, I love, I loveyour post.
I love how you keep it so real.
You're really trying to sharegood, evidence-based information
, care, just what's going on inyour office so that so many
families can see what a goodfood allergy journey can look
(01:08):
like.
So I'm so excited.
Thank you for joining us today.
Speaker 2 (01:13):
I am excited to be here, alice.
You're great and I think we'reon the same page.
No, we're on the same page.
We're just trying to educatepeople.
You said just keep this talkreal, like me.
And you are just chatting, justvirtually chatting, so I'm
happy to be here.
Speaker 1 (01:26):
Well, awesome.
So I think what I want to startwith is really just asking you
how did you find yourself inthis part of your career with
such a great focus on foodallergy?
Speaker 2 (01:41):
So I probably started , probably 2014, 2015.
And honestly, not on purpose,it was Hugh Wyndham.
Dr Wyndham, who's one of theOGs, the godfathers in food
allergies, and he's very ethical, very by the books.
He was my mentor, one of myattendings in fellowship.
Oh my gosh, I didn't know that.
Yeah, yeah, yeah, it's a weirdbanter, but he's my attending.
I love that.
(02:01):
He's been on the podcast.
Yeah, oh, he's great and youcan tell he's great.
And he sent me someone that wastraveling from Atlanta to Tampa
to get treatment for peanutallergy 2014,.
No, maybe 2013.
I don't know.
And I'm like Hugh, what are youdoing?
This is kooky.
And then he's like Tom, itreally works, it's good.
And I trusted him.
And then he was the one and itgame changed.
(02:24):
It was a game changer for thatfamily.
And then I started learningabout it.
I started reading the articlesI presented at Emory Journal
Club.
I was like learning and I waslike, if he does it, yeah.
And then eventually I was likeall right, let me start dabbling
it.
And then I was like this seemslike it works and this was
before Palforzia and soPalforzia, but all the data was
(02:45):
out there using peanut flour.
The company was actually out ofGeorgia Bird Flour, peanut
Flour and I was like we couldjust follow this and I probably
started with peanut, probably2015-ish.
Speaker 1 (02:58):
I love that.
And wait, let me pause you fora second.
If you're joining us, you're aparent and you're somewhat new
to the food allergy space,especially when it comes to
peanut allergy.
There's currently oneFDA-approved product to treat
specifically peanut allergy.
There's two FDA-approvedproducts to treat food allergies
(03:20):
.
One is omalizumab or Zoller.
It's an injectable medicationthat decreases the likelihood
that someone will haveanaphylaxis if they accidentally
ingest their allergen.
And then there's Palforzia,which is defatted peanut flour,
which is what Tom is referringto, regarding there only being
one, or what Palforzia is, andit was before Palforzia, because
(03:44):
Palforzia came out I believe itwas February of 2020 is when it
got its FDA approval right.
It was like right before COVID.
Speaker 2 (03:53):
Honestly, I don't know, because it was just peanut
flour, can I guess?
Speaker 1 (03:56):
why you don't know.
Yeah, because I'm like Becauseyou've already been using other
real peanut food that a parentcan go to the grocery store to
get, yeah, years prior.
Speaker 2 (04:11):
So I don't know, I haven't used it and I don't
think now I think it's beenfalling out of flavor.
To be quite honest, I thinkit's now like everyone kind of
knows, like what is?
The emperor is wearing noclothes.
Whatever they say, they're justpeanut flour.
Come on man, Come on man, Stoptalking about this.
Speaker 1 (04:22):
Yes, so I actually have some thoughts on Palforzia,
though, and I did a blog postwhere I think I wrote the nine
reasons Palforzia has not donewell, and one of the reasons is
this is anecdotal.
So if you listen to thispodcast regularly, you know I
really like to live in evidence.
I like to gain as muchinformation as I can from
(04:44):
evidence, but at the end of theday, some of this is coming from
what are we seeing?
And a lot of evidence-basedmedicine comes from somebody
making an observation and thendoing some science to figure out
what's going on.
And so, with it being defattedpeanut flour and some of my
colleagues who have, kind oflike, dipped their toes into OIT
(05:06):
by just doing Palforzia,they're getting a lot of belly
aches in their kids.
Now, historically, I have donepeanut butter for OIT since I
started in either 2018 or 2019.
I had one kiddo earlier thanthat, but I've done peanut
butter and I think peanut butteris great because it hangs out
in the mouth.
(05:27):
It's sticky.
We'll talk some about slit andhow we think all this immune
stuff actually works, but Ithink the most whole foods we
can use for immunotherapy thebetter.
So I don't really likedefatting it.
I actually think it might messwith the digestion and cause
more of the upset tummy.
What say you, tom?
Speaker 2 (05:49):
So I would say it's your podcast, but I'm allowed to
disagree.
Speaker 1 (05:54):
I love it.
Yes, bring it on.
Yeah cool, so I would say Iron,sharpens, iron, yeah, yeah,
yeah.
Speaker 2 (06:00):
Well, I think the rookies that are doing the OIT
and saying they're having issueswith Palforzer because probably
the people who are doingPalforzers aren't doing it too
much but I think what they'redoing is they're probably trying
to get, they're probably tryingto do it on the really allergic
kids which I believe.
So their IgE is greater than100, greater than 50.
And they're probably aiming atthe high doses and the data that
(06:24):
you do.
Yeah, you're going to getproblems, that's true.
Speaker 1 (06:26):
So that's so interesting because I feel like
I hear from families that I'veheard multiple times and I see
on social I totally lurk in someof the groups that, oh, I've
been told that my child is tooallergic for OIT.
Speaker 2 (06:40):
Please, so okay.
Speaker 1 (06:42):
All you go, find some All right.
Speaker 2 (06:45):
This is what I'm going to say is what are you
calling OIT?
Because that's what the messagecomes out as, and you're going
to see a post on this, because Isay I just did a post on how
spicy do you like your chickencurry?
Because all chicken curry isnot the same and all OIT is not
the same, and I think that'simportant to say that Everyone
wants to trend this.
Oit is not the same and I thinkthat's important to say that
everyone wants to trend this OITworld Like it's one big thing,
(07:08):
like OIT is one thing.
That's not how it is.
Just like.
All right, this is for patients.
But I'm going to talk to otherallergists.
We know there's a difference inreaction rate between the red
vial and the green vial.
Right, there's a difference inreaction rate of food
introduction.
Call it oit, call it.
So.
When you're aiming at 300milligrams of protein, which
(07:29):
palforzia did, which they did totry to get approved zolair,
you're going to get more errorsor more issues.
I should say what if you'reaiming at 50?
What if you're aiming at five?
So that's a long answer tothere is no number that you
can't do.
Food introduction we just mighthave different goals.
Speaker 1 (07:48):
And I'm going to connect the dots here for our
listeners.
So when he's talking about vialshe's talking about when we do
allergy shots we start with likefor pollen allergy, for cat
allergy, things like that.
We do allergy shots and we havefor decades small amounts
injected over a long period oftime teaches the body to
tolerate those allergens.
But what you're getting at hereabout not necessarily pushing
(08:10):
the dose so high is maybe twothings One is being on a low
dose for a long time can be veryhelpful, and two in growing
tolerance, meaning getting kidsto freely eating, possibly not
always, but possibly Highly,possibly, highly, possibly.
But two, getting kids to whatreally should be everybody's at
(08:35):
least everybody's goal regardingany immunotherapy of decreasing
the likelihood of a severeallergic reaction I talk about.
There can be two goals with OITreally.
One is let's get kids bite safe, meaning if they accidentally
eat a bite of their allergen,they won't have a severe
allergic reaction, hopefully noreaction.
But then that other goal that'salways in the back of my head,
(08:56):
regardless of the age,regardless of what the IGE
number is, is let's see if wecan drive this bad boy home and
get to freely eating and overtime get this thing in the
rearview mirror.
Speaker 2 (09:10):
Yep, so I agree, and it all depends on the patient,
it depends on the case, itdepends on the numbers.
We're starting with theirsensitivity IgE numbers talking
about blood work IgE numbers.
Ige numbers talking about bloodwork, ige numbers, and so I
don't, I don't.
I on my post, and with bothpatients and allergists and
(09:30):
doctors and providers, I wantthem to know when you label OIT
as one big thing, you don't.
That's not the details, thedevil's in the details.
And so what, alice, when youasked me, hey, my numbers are
too high for OIT, I'm like areyou too high for 5 milligrams,
10 milligrams?
And we know you mentioned theFAST meeting.
Right, we've been doing thatfor what?
(09:51):
Seven, eight years and we usedto aim at super high doses.
Now we know you go low and slow.
You get there.
You know, maybe what is it?
Tortoise in the hair?
Maybe don't go that, don't bethat fast.
Buddy.
Us in the hair, maybe don't gothat, don't be that fast buddy,
slow and steady, and it's not arace.
Yeah, so I, I and I think whenwe talk about this we're going
to hear a lot of agendas ofpeople like giving a negative
(10:15):
point on OIT because they weregoing so high and these reaction
rates and so.
So that's when you said, hey,that going back to the Balfour's
year thing, I think justdepends on the case and it was
somewhat immediately available.
Then COVID happened.
Speaker 1 (10:30):
So I don't think anybody was doing a whole lot of
starting Palforzia then, but itwas 2020.
(10:53):
People have been doing OIT foryears before that.
So people who were already veryengaged allergists, who were
already very engaged in thespace, had already been using
products that they were verycomfortable with, that they
could purchase, that theirfamilies could, their you know,
their patient families couldpurchase at the grocery store.
Whatever the case may be, and Imean I'll I agree that as a
(11:17):
doctor, like if I getcomfortable with something, it
it's going to take a lot ofevidence to move me over into a
different camp.
And I know there's some argumentthat oh well, if you're not
using the Palforzia capsule,then do you really know how much
dose they're getting?
And do you really trustfamilies to how dramatically I'm
(11:38):
saying this do you really trustfamilies to measure their
allergen correctly, measuretheir allergen correctly?
And my response is teaspoons,tiny teaspoons, milliliter
syringes.
They're all appropriatelymeasured.
The whole point of OIT is to below and slow below the reaction
threshold.
And If I don't trust a familyto give a child the correct dose
(12:03):
of Tylenol, then maybe I wouldnot trust them to give their
correct dose of peanut butter,but most families can do that,
and so we have to trust ourfamilies to work with them.
And so I think it's really kindof insulting to families when
we're like, oh well, we can'ttrust you to measure this, this
(12:25):
has to go through big pharma,you can't measure this.
Wow, this is getting reallyspicy today, tom.
Speaker 2 (12:31):
Well, also right.
Part of it is because there's alot of you are our meeting and
it is what it is.
Right, Like there's a lot offinancial incentive to tell
people that this is somethingdifferent.
Right, Like I've gotten, nowthat I've done social media, I
probably get a call or a DM aweek, maybe more, from
(12:53):
allergists trying to learn aboutthis, but we're not getting
told because, like, they won'tlet this will not go on our
academy or any big meeting.
You know that right, Becausethere's big sponsorship to make
us think that certain meeting.
You know that right, Becausethere's big sponsorship to make
us think that certain things aredifferent than others.
Right, and so I don't.
It's not all, it's just who'sfunding that narrative.
(13:17):
And I've said that numeroustimes.
Speaker 1 (13:18):
Well, ultimately the way studies get funded is
there's a drug that couldpotentially help treat somebody
and that drug is made by acompany and in order for that
company to make the drug, I meanthey do have to raise money.
Those studies cost so muchmoney.
But I mean you're hitting thenail on the head.
(13:40):
I remember when I was infellowship it was so hard to
even contemplate writing an IRBan institutional review board
application to do a study withsomething like peanut butter or
pasteurized liquid egg white,because it's a food, it's not a
drug.
And the whole concept of usinga food to treat a condition is
very like, very strange toregulators minds, very strange
(14:03):
to regulators' minds.
And when you do follow themoney trail then it is hard to
say, oh well, okay, well, we'rejust going to do all this big
study but then not have some wayto get reimbursed or make money
from it.
Like I get that.
You know what I mean.
But at the end of the day, thisis where healthcare is not
(14:25):
traditional business.
And look, I'm all aboutcapitalism.
This is not a political podcast.
I think capitalism done welldoes serve our communities.
Greedy capitalism is somethingcompletely different.
It's not what I'm talking abouthere.
At the end of the day,healthcare is different,
different and health care has tobe treated differently.
(14:45):
We could go on and on abouthealth insurance and all of
those things right now, but it'sa challenging situation, I
would say, because we do wantall of this data.
And what I think is sobeautiful, tom, and how we even
got connected, really is becauseof FAST, the Food Allergies
Support Team meeting in Dallas,because of this amazing network
(15:08):
of OIT allergists.
I think what Dr Wasserman saidthis looks like 700 people on
the email list or something likethat, which, compared to how
many kids and adults have foodallergies, is kind of small.
We're still the minority is kindof small.
(15:29):
We're still the minority, yes,we're still the minority, but
it's nice that, how muchinformation we all share.
I mean, I check my email and Iusually have at least two to
three emails from members ofFAST OIT.
We're all like talking aboutdifferent cases.
What we're seeing you know whatwe're seeing with NEFI that's
big on the chain right now Like,do we think it's working as
well as the auto injectors?
(15:50):
What different foods are weusing for different OIT?
Or now with SLIT.
So it's nice to shareinformation.
Healthcare is just, it's such aunique, a unique beast and
that's why I think, at the endof the day, it's so important
for families to be very mindful,be informed, get your
information from from goodresources and that's again why I
(16:13):
love your Instagram, cause it'sit's not sensational, it's not
sensationalized, it's just, it'sjust real.
And have good discussions withyour allergist.
And if you're a parent, you'relistening to this or watching
this on our YouTube and you'relike wait, my allergist hasn't
talked about OIT at all.
Then ask your allergist hey,what do you think about OIT for
(16:35):
my kiddo with an anaphylacticfood allergy?
And ask if they don't do it,then ask okay, well, who do you
know that does do it?
It then ask okay, well, who doyou know that does do it?
And I would like to get anopinion from them, because it is
high time, to your pointearlier, that more patients know
about this option.
Speaker 2 (16:56):
I would argue this, and I don't.
First of all, my colleagues, mybuddies, my guy that I trained
with they don't offer it.
So I want to be very clearbecause your allergist doesn't
offer it doesn't mean they'rebad doctors.
It just might not be theirthing and so that's okay.
Just make sure you find someonewho is their thing.
So that's why I'm like ask themand they might just say, hey,
(17:17):
our academies don't recommend it.
Well, there's reasons why ouracademies don't recommend it.
Our academies, we didn't gettrained.
I don't think they don't.
Speaker 1 (17:23):
Not, I don't think they don't not recommend it
though.
Speaker 2 (17:28):
But I don't think if they recommended it, we wouldn't
be having a separate FASTmeeting.
We'd be having a session on howto do OIT and we wouldn't be
having.
I like the patch test sessions.
I like the rhinoscopy sessions.
There should be a foodintroduction.
I've actually went out to them.
I emailed them and said can Ido my talk?
And they're like we have.
And it was actually one of thefolks does OIT, but she's like
(17:51):
we're kind of regulated on howwe do some of these talks.
Speaker 1 (17:55):
So I will say some of that is probably to obtain
continuing medical educationcredits and so to get that CME
hours, which a lot of us go tomeetings to obtain the CME hours
and the FAST.
We don't even mess with thatbecause, you're exactly right,
there are regulations there thathave to be followed so that
people can feel good about theeducation that they're receiving
(18:18):
.
I will say the FAST meeting issome of the best, most practical
information.
They're the best meetings handsdown I've ever attended.
Speaker 2 (18:29):
But then, what do you think?
Speaker 1 (18:30):
about and I get no CME from it.
Speaker 2 (18:32):
No, we get no FAST meeting is the best.
You know.
I spend a lot of.
I spend hours, you know, doinglectures.
You spend hours, hourspreparing for it.
Right, I pay for it too.
I don't give a, I pay.
It's not sponsored.
I pay my hotel, which I love.
I would never not, because Ithink it's very sincere, it's
(18:52):
the most cleanest.
We're just trying to good work.
Speaker 1 (18:54):
Yeah, so I agree with you.
It's genuine.
You know, the information beingpresented is just like
unfiltered.
Speaker 2 (19:02):
Unfiltered, and people with a passion that want
to teach, like we lose clinic,like we just we just think it
should be out there.
We think I know, I think wejust sorry, I just want a big
thunder.
Yeah, um bolt, I don't evenknow that, so, um, no, but I
think, I think it's I, you know,and now it's us, the guys who
have more experience, justgiving back.
(19:22):
You know, the younger guys, youknow.
Speaker 1 (19:33):
So I love it.
It's on my calendar.
I know it's a great meeting,okay, so I want to move into
Slit, though, and then talk alittle bit about that.
I also love your little peanutpuff approach.
I love Mission Mighty MeatPuffs.
I do some spokesperson workwith them on occasion.
Speaker 2 (19:46):
There's my disclosure .
I just did a podcast with themyesterday, but I'm not a speaker
, I do it for fun.
They live in Atlanta.
Speaker 1 (19:54):
How I got connected to them was my in-laws live in
Atlanta and a few years ago mymother-in-law saw in the local
newspaper this article aboutthem.
She cut it out, brought it toour family beach trip and I was
like, oh my gosh, this isamazing.
So I emailed her, catherine.
I was like, hey, do you want tobe on my podcast?
And it was a lovely episode.
So I love their mission missionreminding me.
(20:15):
I love how they're working sohard to make their products
really good products.
But I really liked how you'redoing some OIT with their
products and I mean it's just soreal world right.
And also how you're thinkingabout SLIT and OIT.
Let's dive into that, sir.
Speaker 2 (20:37):
So let's talk about SLIT.
So SLIT a lot of people aretalking about, and SLIT is
sublingual, where you basicallyput the food allergen under your
tongue and absorb it.
And SLIT is sublingual whereyou basically put the food
allergen under your tongue withan absorber and the thought is
that it lets your body tolerateit.
Right, it's all.
Most of the SLIT data is basedon Edward Kim's data.
Who's out?
Speaker 1 (20:54):
of California.
He's brilliant right.
Yep had him on the podcast.
It was great data.
Speaker 2 (20:59):
It was done very well .
So I don't disagree with hisdata and I don't, but he
mentions it himself and heactually says it.
He did a Canadian podcast wherethere are one to two-year-olds.
Most of the kids were liketwo-ish and they put it under
their tongue.
But I've said it numerous times, they can't hold their potty.
(21:19):
There's no way they're kiddingon this, they are swallowing it.
They're swallowing and hedoesn't.
And he's credible.
He doesn't say that's not thecase, right.
Speaker 1 (21:29):
He's the real deal.
Speaker 2 (21:30):
Yeah, he's the real deal, he's keeping it honest.
So, in my opinion, they'rebasically taking five milligrams
of the protein of peanut,because that's the only one
that's come out.
They'll get an FDA-approvedproduct.
They're working on that andthey're working on tree nut too,
but it's just five milligramsof the protein swallowed and it
(21:50):
works low and slow.
It worked on the kids.
It worked really well.
So I just think it's anotherway of low dose OIT, I think the
caveat is the kids.
Speaker 1 (22:04):
They I have to look back at the paper, but what I
advise my families who are doingSLIT is no food 15 minutes
before, 30 minutes after, if atall possible, Definitely five
minutes before and 15 minutesafter, so that it's literally
just a fairy spit of allergen intheir mouth and that's it.
So just full access there, asopposed to with OIT.
(22:27):
For parents who are listeningand aren't super familiar with
OIT, we like OIT to be dosed ona happy tummy that's how I
describe it not on an emptytummy.
So a lot of times kiddos willstart to eat dinner and take
their dose, or dose with a snack, and that's so that the tummy
isn't just receiving thisrelatively large load of
(22:49):
allergen relatively largecompared to slit.
To put it into perspective, onepeanut has about 300 milligrams
of peanut protein.
So when we're talking aboutfive milligrams, four milligrams
like that is such a smallamount.
That is an amount that a lot ofOIT allergists will start OIT
or maybe a few doses before thenwill start OIT, and that's the
(23:10):
maintenance dose with slit.
When I talk about should we slitor should we OIT with my
families, it's a lot of.
What season of life is thefamily in?
Would they even be able to dothe OIT one hour before, two
hour after, dosing, rest periodof not you know running track,
doing baseball, all the thingsright?
(23:32):
And if they're not, then we'releaning a lot more into slit
because the safety window is alot less and that's very
heterogeneous amongst allergists.
I say 15 minutes before, 30minutes after, but I think some
people are just like whatever,it's such a low dose, it's not
going to cause a problem.
Speaker 2 (23:49):
What are your thoughts on that?
I would say I agree.
So it's interesting because youwere talking about slit on your
baseball players, because yes,I think slits are good, or low
dose OIT, which I would say issimilar are good on your
teenagers or the kids who arebusy and kind of.
The ship sailed.
The IG is already up.
Alice.
You already published the dataon the little ones On the little
(24:11):
ones.
Oh, thank you, yeah, youpublished that right, I've
quoted you like numerous times,like every FAS meeting, I think.
The publication came out in2023 from Cleveland Clinic and I
just reset it Like 22 kids.
They gave them Bomba.
They got them them to 500.
No, we did peanut butter withthese little tiny.
Oh, I got the one.
(24:33):
I did one.
Oh, maybe peanut butter.
I knew it was protein, though500 milligrams of protein was
the end point, and that'sbecause of that, that's my goal.
So sorry, I switched them toBomba.
So with the goal, that's fine,yeah, but with the goal of 500
milligrams of protein.
Speaker 1 (24:48):
So that's how I use that number.
You know why I picked 500milligrams?
No idea.
Because when I started doingthis tiny teaspoon protocol it
was after I came home from aquad AI meeting and I was like I
can't keep telling familiesthere's nothing I can do, like
there's clearly something I cando to help their child with food
allergy.
And my mom had sent me thesevery cute teaspoons, like years
before, because she thought theywere cute.
She thought I would think theywere cute.
(25:09):
So I was reading Brian Vickery'spaper on his preschool OIT and
I was like, well, how can Iconvert this into something
that's like feasible, likepeanut butter, that's normal,
right and very practical?
I'm a simple country doctor.
How can I just make this easyand how can I make it effective?
And when you look at thatVickery paper, he compared kids
who did 300 milligrams of peanutprotein to 3,000 milligrams of
(25:31):
peanut protein.
The kids got to the same amountof tolerance.
They did equally as well,except the higher dose kiddos.
They had more reactions.
I'm like, well, I don't wantreactions, I just want
effectiveness, right.
But I was like 300 milligrams.
Well, I mean, I just wanteffectiveness, right, but I was
like 300 milligrams.
Well, I mean, I just want tomake sure that they're getting a
real dose, and what if there'ssome variation in the dosing?
So why don't we go up to half ateaspoon?
(25:51):
That's about 500, 600milligrams.
That sounds good to me.
Speaker 2 (25:58):
And that's why we did it.
Practical application ofscience.
So I aimed we're saying almostthe same, different ways of
saying the same thing with mybabies.
I try to get them three Bomba,then six Bomba.
I leave them with that About500 milligrams of protein.
Speaker 1 (26:12):
Are you using more Mission Mighty Me than Bomba now
?
Speaker 2 (26:15):
I like my Mission Mighty Me on my tree nut ones.
I do a lot of those for thetree nut ones.
So we were talking about Slitright, and we're trying to get
them to five to 10 mil.
So slit dose is about fivemilligrams of protein, five to
10 milligrams plus or minus.
So teenager comes to me 14 yearold, I have literally three
today that comes to me Peanut at15, cashew not too bad too, it
(26:40):
gets you, gets you.
But so, and I've gotten burnedon this one.
But usually I'll build them upand then I'll put them on one
Mission Mighty Me puff, itdissolves and I'll either send
them on one or two.
So that's my low dose RIT,that's my slit and it's easy,
that is easy Not having torefrigerate, not having to use
(27:01):
glycerin.
And it dissolves.
And you got that five to 10milligrams.
And the problem is if that gets.
I think I'm doing the samething that Edwin Kim's going to
do with his FDA approved slant.
I think it's the same thing,literally so and he's coming out
and they're publishing it.
They're going to try to do itfor Trinod too.
I think we're talking the samething, I know I know.
Speaker 1 (27:24):
But you know, what's so nice about the studies and
the pharmaceutical products isthat, especially like when
Palforzia came out, it put theperiod on the validation of this
works.
You know, it's no longer justin a journal, which I mean to us
being in a journal, it's likeI'm published in a peer reviewed
(27:44):
high impact factor, not pay toplay journal.
Yes, you know, but gettingthrough the FDA is.
We won't go down the rabbithole of FDA right now.
Speaker 2 (27:56):
And I don't deny that .
That's why you need the studiesto prove it, studies to prove
it.
I'm just saying when someone'slike saying oh, I'm doing SLID
or this because thisFDA-approved product will likely
there's multi-millions ofdollars getting this to come out
, I'm just not sure it'sdifferent than one or two Mighty
Me Puffs Right.
Speaker 1 (28:14):
I'm with you.
I'm with you.
I love this conversation.
Okay, I know we're going up ontime.
I could talk to you forever.
Let's get to those socialquestions, because your amazing
team asked for some questions.
So what do we have?
Speaker 2 (28:30):
The big question one I get a lot is why aren't more
allergists or academicinstitutions doing this?
Speaker 1 (28:36):
I have this conversation regularly.
I will say why are not moreinstitutions doing it?
I would say because very rarelyare doctors leading truly
leading institutions.
And if doctors were trulyleading institutions, then there
would be significantly lessbureaucracy to get these types
(28:58):
of protocols approved, where allyou need is to bring in peanut
butter to start to treat achild's medical condition.
There's that.
There's well.
Now we have an FDA-approvedproduct, the Palforzia, the
Zoller.
So these are FDA-approved.
So maybe we, as a biginstitution, maybe we're
supposed to use the FDA-approvedones before we try peanut
(29:19):
butter that's not FDA-approvedLike I've heard that before,
when Palforzia first came out, Iheard that the institution was
not permitting it because theway Palforzia was working I
don't know how it is stillworking, but they would actually
mail it to the patient, which Iknow they do do that some and
the patient would bring in theirdose.
Well, the hospital was notpermitted to give a dose of
(29:43):
something that did not comethrough the pharmacy.
So there is that.
And then there's the trainingbit, and how allergists are
trained is you can be aninternal medicine physician, do
an internal medicine residencyor a pediatrics residency or do
med-ps, which is what I did,which is do both, decide to do
(30:04):
both, but you are applying forall the same allergy spots.
There are not nearly enoughallergists in this country to
take care of all the adult andpediatric allergy patients.
And when you're applying sothose internal medicine and
pediatrics residents, they'reapplying for the same.
It's not like just a pediatricsallergy fellowship or just an
adult.
It's not.
And our board is a separateboard.
The American Board of Allergyand Immunology is separate from
(30:25):
American Board of Pediatrics,american Board of Internal
Medicine, and we are vying fordifferent spots.
So we don't have enoughallergists.
And then in the institutions,because of the multiple factors
I listed I probably forgot somethey're not doing a lot of the
OIT, so then they're not gettingthese fellows which is a
trainee in allergy andimmunology, it's called a fellow
(30:46):
.
They're not getting taught howto do it, so then they're not
coming out of training doing it.
And then you're exactly right,they hear and especially
allergists who have been inpractice for a while they've
heard a lot of the bad thingsabout OIT and not as much of the
good stuff, which again is oneof the reasons I love what
you're doing with your Instagramand I was so happy to have you
(31:07):
on the podcast.
So that's my answer.
What do you say?
Speaker 2 (31:10):
My like five minute answer.
Well, actually you understandthe academic aspect more than I
do.
Like I didn't know about thedistributing it and stuff like
that.
I agree with everything yousaid, but I would caveat that
also pharma's big right Like allthe guys that are publishing
that speak, the leaders at ourmeeting are pharma.
They're great, but they havepharmaceutical sponsored studies
(31:33):
right, and so there's somethingto do like there's some agenda
in that, and so I think thatalso influences a lot of the
training and a lot of likethey're not training, they don't
know and they don't.
I don't like.
Scripps did it, you guys did it, but not many of our leading
(31:54):
institutions in the US, inCanada, they do You're talking
about the US Clinic.
Yeah, cleveland Clinic right.
Speaker 1 (32:00):
That's what I saw.
I'm in my own practice now,since 2021.
Speaker 2 (32:03):
No, no, but at least you're authored on the one that
I posted.
Yeah, I was at Cleveland Clinic.
I love my Cleveland Clinic.
Yeah, yeah, yeah.
Speaker 1 (32:10):
So we had amazing leadership with Dr David Lang
supporting the development ofthe Food Allergy Center of
Excellence at Cleveland Clinicwhen I was there, yeah, but I
still saw the hurdles, thebureaucracy, everything we had
to go through to get to thatpoint and that's why I'm so like
intricately aware of thechallenges.
(32:31):
But because we had thatchampion and Sandy Hong and
these other just like reallygreat people at Cleveland Clinic
and at least when I was therethey were pushing like physician
leadership and at least when Iwas there they were pushing like
physician leadership, we got itto where it needed to be.
You know, and if you don't havethat it makes it really hard
and you're right with the pharmait gets really.
(32:52):
It's tough and you know it'stough to sit in there and we can
all have disclosures, right.
So I mentioned I'm aspokesperson for Mission Mighty
Me Like that's great right.
What else?
Oh, mission mighty me Likethat's great right.
What else?
Oh, I do some consulting withKaleo.
I've stocked Kaleo foreverbecause I think it's a very safe
.
But when I was polling thegroup, you know, talking with
our fast OIT email, you know, Iput that in there like hey, like
(33:15):
I have a disclosure here.
But one of the reasons, like Iwork with Kaleo is because I
believe in their product.
I've seen it work for years,long before I've been a
consultant for them, you know.
But it is to your point.
It's hard to hear like talkafter talk about how great this
drug is or that is, when thereis so much behind it that helps,
(33:38):
you know, put food on someone'stable.
Speaker 2 (33:40):
Yeah, it's hard, like , so I agree with everything you
say, but I do think you havethere's some financial biases
that you have to think andthat's part of the reason why
our bodies are not differentthan the bodies in Canada, you
know, but like, but the dynamicsare right, like that makes
sense.
So I love the Canadian side.
(34:02):
I absolutely love, I love, Ilove those guys there.
Like I don't even know thempersonally, but I love what they
do, they publish awesome stuff.
Speaker 1 (34:10):
Okay, next question.
Speaker 2 (34:12):
I have one this is you kind of asked me this but
extremely elevated total IGE towhatever, whatever food.
What can we do?
Speaker 1 (34:22):
So those are the kids that I'd say need support the
most.
Now, having a high numberdoesn't necessarily mean they're
going to have a more severereaction.
Right, number and severitydon't necessarily correlate, but
likelihood of being allergicdoes correlate, and especially
in these kids where the numbersaren't going down like that's a
total bummer right, where likethere's a baby diagnosed and
(34:42):
it's like, oh well, let's waitand see.
(35:03):
And then they come back a fewyears later and eczema can just
have the body rev up making awhole bunch of immunoglobulin E,
which is the allergic antibody.
But yeah, I mean, I think thehigh numbers, those are the kids
that need support.
Speaker 2 (35:16):
So I would agree with you and you've seen my case.
I'm always very specific ontelling people the numbers, like
on my case, right.
I'm always very specific ontelling people the numbers, like
on my case.
I want people to see thenumbers that are treated.
It's very.
I try to be detailed, maybe toodetailed, but yeah, and it just
depends on the case, right.
So, for example, if thepeanut's greater than 100, I'm
(35:36):
not going to aim for 300milligrams of protein, I might
aim at a lower dose, I might goat the slit, I might go at 10.
I might go at 20, but now let'sswitch that up.
And now let's say it's the milkand the milk is 70.
And I'm like man, but the kidcan't eat milk.
That hurts him every day.
So I'm still going to say Iwould still consider treatment,
but now we just go slower.
It might take me six months toslowly roll that in, but I'm
(35:57):
still aiming to get that kid tofree eat, because milk it's hard
to avoid milk.
It is hard, especially our, ourmilk egg kids, yeah, and so my,
and like my egg ones, I mightnow aim to just get them to eat
in the baked form.
So so, so, cause now I don'twant Joey not being able to get
a birthday cake at someone'shouse you know.
Speaker 1 (36:19):
So a million percent.
So much of this is quality oflife and improving the child's
quality of life and, honestly,the family's quality of life.
You know there's so muchanxiety that goes along with
having a child with food allergy.
If there's something we can doto intervene to make it less
likely that a child's going tohave a severe allergic reaction,
we need to do it.
Speaker 2 (36:39):
Yeah, so so my take on all of that is that options
are there.
Talk to someone who knows andkind of gives you can, can can
walk you through your, your,your choices.
Speaker 1 (36:50):
I love it.
And if you're in Georgia,parent listening, then you
should go see Dr Chaco.
So how many?
You have a lot of offices.
Speaker 2 (37:01):
Yeah, so we're.
We're all around Metro Atlanta,so you have a lot of offices.
Yeah, so we're all around MetroAtlanta, north Atlanta, and
we're happy to help.
We'd be happy to see us, andnot many people, I do think, not
just in Atlanta, but across thecountry most parents are still
hearing that avoidance is theonly option.
Or they might be saying thatdoctor only offers avoidance or
Zolaire, and I think that's mymessage to everyone listening
(37:25):
that those are not your onlyoptions.
Speaker 1 (37:27):
Right, it's great to have those.
Avoidance is always an option.
It's great to have Zolaire as atool in our toolkit.
I appreciate Palforzia, butthere's more.
Speaker 2 (37:38):
Yes, and Allison, I know, not just us, but there's
doctors like us across thecountry, and so I just want you
all to know that there's optionsout there.
Speaker 1 (37:52):
There are options.
I love it, dr Chaco, thank youso much for coming on the
podcast.
You're awesome.
You're welcome back anytimethis was so much fun.
Thanks so much for tuning in.
Remember I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned today.
Like subscribe, share this withyour friends and go to
(38:14):
foodallergyandyourkiddocom,where you can join our
newsletter.
God bless you and God blessyour family.
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