September 2, 2023 • 28 mins
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If you have heard of OIT or SLIT (oral immunotherapy and sublingual immunotherapy, respectively), then you've probably wondered how these therapies treat food allergies and, if they are so great, why isn't everyone doing them? Well, in part, it's due to potential risks, but there are also some other factors to consider.
Join Dr. Hoyt as she discusses all this with her colleague Dr. Sakina Bajowala. Dr. Bajowala is a board-certified allergist with specific expertise in the treatment of food allergies. She practices outside of Chicago and helps families navigate the world of food allergy and, in many cases, helps make her patients significantly less allergic to foods. Dr. Bajowala is a Fellow of the American Academy of Allergy, Asthma and Immunology and is incredibly well respected by her colleagues in the OIT space.
Note: the doctors mention a couple resources during this episode:
https://www.foodallergycounselor.com/
https://solidstarts.com/
Looking for one-on-one time with a food allergist to finally get your food allergy questions answered? Sign up for Food Allergy Office Hours for Parents.
Are you a pediatric clinician and you want to stay up-to-date on food allergy information that's relevant to your practice? Join the Food Allergy Pediatric Hub.
Are you in need of an allergist in your area?
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Would like to become a patient? Reach out to the Institute!
Does your kiddo's school need help with medical emergency response planning? Check out the non-profit Code Ana.
This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Speaker 2 (00:01):
Welcome to.
Speaker 1 (00:02):
Food Allergy and your Kiddo with Dr Alice Hoyt the
podcast about demystifying foodallergies, diminishing allergy
anxiety and taking back control.
Let's navigate this challengetogether with evidence-based
information, scientific researchand tried-improven practices.
And now here's your hostboard-certified allergist and
(00:24):
immunologist specializing infood allergy, Dr Alice Hoyt.
Speaker 3 (00:30):
Hello and welcome to the Food Allergy and your Kiddo
podcast.
I am your host, dr Alice Hoyt,over the moon excited about
today's guest.
Dr Sakina Bajawala is aboard-certified allergist and
pediatrician and she practicesin the western suburbs of
Chicago.
And Dr Bajawala you might knowher from her writings on Web Nd.
(00:53):
Also, she is one of thoseamazing docs involved in solid
starts that is all overInstagram helping new mamas and
papas be able to give theirkiddos age-appropriate food, but
not just mushy, mushy, mushyfood.
So I'm so excited to have youtoday, sakina.
(01:14):
Welcome to the podcast.
Speaker 2 (01:16):
Well, thank you, Alice, for having me.
I'm delighted to be here.
Speaker 3 (01:23):
Today, what I really want us to talk about is really
optimizing safety duringimmunotherapy, specifically oral
immunotherapy, sublingualimmunotherapy, the food
immunotherapies ordesensitization.
And so, if you're new to thepodcast and listening, we've had
lots of episodes one, what isoral immunotherapy?
(01:47):
I'll talk about what issublingual immunotherapy, but
today I really want us to focuson the safety of it all.
And so, dr Bajawala, when afamily first comes to see you
and you'll have the discussionabout desensitizing their kiddo
to a food, what are some ofthose first safety questions you
(02:11):
feel you're feeling the most?
Speaker 2 (02:15):
I would say the number one fear and concern that
families have when we broachthe subject of food allergen
desensitization is the risk ofanaphylaxis.
After all, for most families,the reason that they're even
considering food allergendesensitization in the first
(02:36):
place is they would like toavoid anaphylaxis in the future.
So many of them haveencountered literature or online
articles claiming that the riskof anaphylaxis from a food
allergen is actually increasedduring food allergen
(02:56):
desensitization compared tostrict avoidance, and that, of
course, is concerning to them,and so they're always asking if
the whole point of this is toavoid anaphylaxis and there's an
increased risk of anaphylaxisduring food allergen
desensitization, what are wedoing here at all, and what are
you going to do to minimize mychild's chances of experiencing
(03:20):
such a reaction, and what can Ido as a parent to do the same?
Speaker 3 (03:26):
And how do you answer that very specific, yet very
common, super common question?
Speaker 2 (03:35):
Yeah, I would say.
Well, the first thing I do isexplain the difference between
overall incidence of anaphylaxisduring a course of
immunotherapy and compare thatto the risk of anaphylaxis as a
(03:59):
function of the number ofexposures, right?
So when you're comparing howoften someone might experience
an allergic reaction and usethat as the numerator of a
fraction and then divide that bythe number of exposures during
that time period as adenominator, that ratio is more
(04:23):
reflective of how effectiveimmunotherapy is.
So in the event of strictavoidance, that ratio is higher
than what you would see duringthe course of food allergen
desensitization.
And the reason as a function ofnumber of exposures, the rate
(04:45):
of anaphylaxis is relatively lowduring oral immunotherapy is
because, as allergists, we areworking very hard to optimize
baseline health prior to theinitiation of treatment.
So we think about this conceptof a bucket that holds your
(05:06):
allergic inflammation.
And there is only so muchinflammation that this bucket
can hold before it overflows andsays I give up, I'm going to
have a reaction, right.
And so many different thingscontribute to this bucket.
If you have uncontrolled eczema, that fills the bucket up a
little bit.
If you have poorly controlledasthma, it fills the bucket a
(05:30):
little bit more.
If your environmental allergiesare very, very active.
The bucket is further still.
And then, on top of that, ifyou introduce daily exposure to
a food allergen, you have verylittle space left in that bucket
before it overflows.
Now, if you focus instead onnot being so intent on starting
(05:59):
food allergen desensitization assoon as possible, but rather
take your time and empty thatbucket out Right, so get asthma
under control, get eczema undercontrol, get your environmental
allergies under control.
If there's any constipationissues, get that under control,
(06:19):
all of a sudden the level of thebucket is down here and now you
have more wiggle room to put afood allergen in on a regular
basis with a total overflowing.
So that is job number oneOptimizing baseline health, and
it's enormously important to thesafety of immunotherapy long
term.
Speaker 3 (06:40):
Love that, love that, especially, I would say, with
our asthmatic kiddos and reallymaking sure that, even if they
have what you think is maybemild intermittent asthma, but
then really doing a good deepdive into how much asthma is
(07:01):
that kiddo having, how manytimes is that kiddo wheezing or
coughing with a viral infectionor with allergen exposure, and
really optimizing that asthmaregimen, even sometimes starting
an inhaled corticosteroidsooner than maybe you would if
they weren't starting OIT.
Maybe you try singular, maybeyou try optimizing something
(07:25):
else or a little bit heavier onthe, on the antihistamine or
nasal spray or whatever you wantto do to minimize the allergen,
the allergy load, I guess Iwould say.
But I find that I am now muchquicker to try to optimize,
especially asthma, definitelyeczema, definitely seasonal
(07:47):
allergies, but especially asthma.
I agree.
I especially sense with asthma.
We do not want an asthma, wedon't want an asthma reaction.
We don't ever want, I don't everwant, I don't think you ever
want the lungs involved in theseanaphylactic reactions or these
even mild reactions that thencould potentially be worse than
(08:10):
when you're doing every day atrisk of having an allergic
reaction.
The other thing that I like tothink about with OIT and
optimizing safety is really andsort of the numerator-genomic
discussion that you were talkingabout is thinking about when
(08:35):
somebody is having an ingestionof their allergen.
If they're on an avoidancepathway meaning that they're not
on OIT or slit and they have anaccidental ingestion and they
have a reaction.
That's gonna be a completelydifferent anaphylactic situation
than when you're doing oralimmunotherapy and you know that
(08:55):
you're giving your child a veryparticular amount of a very
specific allergen and you havethat safety window, especially
with OIT, with slit, we can talka little bit about the safety
with slit, since it has such abetter safety profile regarding
the daily dosing and the safetywindow, as I call it.
(09:17):
But really just a reaction thatyou have with OIT is gonna be
just so much.
It's a much more controlledenvironment than heaven forbid
those calls that we get frommoms when their kiddo has an
accidental ingestion ofsomething at school and they
don't know how much of it it was, or if it's a kid with multiple
food allergies, they don't knowwhich allergen it was.
(09:39):
And those reactions, with somany unknowns, I feel like they
just weigh so much more onfamilies than the potential of
the OIT reactions Is that sortof in your experience.
Speaker 2 (09:54):
Absolutely right.
The difference betweenanaphylaxis out in the field
versus during oral immunotherapyis that in oral immunotherapy
you have a precise dose underoptimized conditions, under
supervision and so you need toRight and I'm gonna stop you
(10:15):
right there to make sure ourlisteners understand optimized
conditions.
Speaker 3 (10:20):
Whenever we're doing oral immunotherapy especially
for new to the podcast wheneverwe're doing oral immunotherapy
with a family, we give themparameters by which to either
contact us or absolutely do notdose, such as if you're having a
fever, if your kiddo is havinga fever, who's doing the OIT
right, vomiting out in the heat,which I know right now across
(10:43):
the country.
It's just been madness.
So anything that's raising thebody temperature, increasing the
heart rate, those are gonnalower the threshold to have an
allergic reaction.
And so, sakina, I mean you'rehitting the nail on the head.
It's we are under optimalconditions when we're doing OIT.
And one little tangent sometimesif you're not a new listener
(11:07):
then you know that sometimestangents occur on this podcast.
Many times when we havereactions with OIT it is because
there has been an oops.
You're right, he had a feverearlier and I gave Tylenol.
Then I totally forgot, or hehit his arm and so I gave him a
(11:28):
motrin and I totally forgot thatmotrin can lower the threshold
and that I'm supposed to callyou about that or hold the dose.
So definitely those confoundersthat happen.
But yeah, I think we see thesame thing about the.
When a reaction is happeningduring OIT, it's just such a
different, it's just a differentsituation than when it's
(11:49):
happening in the field.
Speaker 2 (11:51):
Yeah, and it can be really easy for families to get
a little bit complacent afterthings have been going very well
for a long time.
So of course we give theprinted out list of safety rules
and of course we have 24-7availability to answer questions
(12:11):
related to oral immunotherapydosing, because I would much
rather that a family reach outto me at 6.30 in the morning and
ask me a question so I can sayyou know what you need to skip
your dose today, rather thanworry that they're going to
bother me and then just say, oh,it probably is fine, I don't
(12:35):
want to call her, give the dose.
And then they got to call meanyway because the kids needing
any Right, right.
So I always say I will never beupset, my step will never be
upset if you call me with aquestion, and so we get a lot of
questions, right.
And so one of the things westarted doing is we realized
that our safety rules apply toall of our patients.
(12:58):
Right, we have a protocol, mycolleagues have protocols, you
have internal protocols and forthe most part our safety rules
as an oral immunotherapycommunity are pretty uniform.
They may not be exactly thesame, but conceptually they're
the same.
We want to make sure that thedose is administered not on an
(13:22):
empty stomach, without a fever,without active illness, without
active asthma symptoms.
We want to control the heartrate and the core body
temperature around dosing time.
We want to make sure that thosefactors that might increase the
risk of having a reaction arecontrolled for so I don't want
(13:44):
kids dosing late at night.
I don't want kids dosing whentheir routine has been
completely disrupted, or if theyhad a horrible night of sleep
and they're exhausted, or ifthey've been out all day.
Speaker 3 (13:57):
Cut out a little bit, but I think what you said is
that you don't want them dosingwhen their routine has been
interrupted and they'reexhausted and sleep deprivation.
Speaker 2 (14:06):
Yeah, we actually have data in peanut allergy
showing that sleep deprivationand dehydration are associated
with an increased risk of peanutanaphylaxis and we can
extrapolate from the data aboutpeanut to making safety rules
(14:26):
for the deliberate exposure ofpeanut and other food allergens
in these patients.
So, knowing that all of us havethese very similar and somewhat
standardized safety rules,we've tried to integrate that
into our protocol.
So we have all of our patientslike log their doses regularly
(14:48):
and there are screeningquestions that pop up.
Before they log their dosesthey say in the last 24 hours,
have any of these thingsoccurred?
If they have, they click a boxand it tells them you need to
reduce your dose or you need toskip your dose today.
Speaker 3 (15:03):
You have an app for that right.
What is the name?
Of your app.
Speaker 2 (15:07):
The app is called the Food Allergy Fix Mobile App.
Speaker 3 (15:11):
Nice, nice.
We'll put a link to that in theshow notes.
That's awesome.
Speaker 2 (15:17):
And you know these rules are things that most
allergists are doing anyway,right?
They're giving it to theirpatients.
So pretty much all patients arebeing asked to follow very
similar rules and, like I wassaying earlier, it can be easy
to fall out of the habit oncethings have been going well for
a while.
So what you mentioned earlier,Alice, those oops moments Pretty
(15:41):
much any time there'sanaphylaxis, when we debrief and
look backwards, we find thatoops moment right, and I think
that's probably your experienceas well.
Speaker 3 (15:52):
Yes, it is, and it's reassuring, right?
It's reassuring that for themost part, kiddos do very well
with oral immunotherapy.
For the most part that there'snot necessarily a lot of big
surprises along the way if we'refollowing a good protocol for
(16:15):
that patient.
I know that I am.
I would say I'm very proactiveallergist, but I'm also very
conservative, and what I loveabout being in my practice is
that I'm not confined by anysort of research protocol.
Right, because the horse is outof the barn like, oh I teamwork
, right, we don't need aresearch protocol for it.
(16:38):
It was nice about it inparticular is that if a mom says
you know what, she just reallyhasn't been feeling.
Well, do you think we should updose Like she doesn't have a
fever or anything?
But I'm like, nope, let's waittill next week.
Speaker 2 (16:51):
That's always air on the side of caution, and I think
most allergists will do that,because it is not a race, it's a
marathon.
Speaker 3 (17:00):
Slow and steady and it's not a race.
Speaker 2 (17:02):
It's not a race, it doesn't matter how fast you get
to the finish line, it justmatters that you're still in the
running.
And I am just like you.
If I get that call I'll say,yeah, skip, it's fine, we'll get
back on track tomorrow.
And people are so stressed I'mlike, oh, but if I miss a day
(17:25):
I'm going to throw everythingoff.
And no, you're not.
I have some patients who missed,for I mean, during the peak of
the COVID pandemic, when peoplewere getting COVID right and
left, I had patients who weresymptomatic with their illness
and they were missing their dosefor seven, 10 days at a time.
And they didn't have to startall over, we just took them back
(17:48):
a little bit, brought them intoclinic, made sure they could
tolerate a slightly reduced doseand built them back up.
And I think having a sense ofreassurance and calm and
trusting the process is veryimportant because you know we've
talked about the organic andphysical aspects of health
(18:12):
optimization in safetyoptimization prior to oral
immunotherapy.
But there's a really, reallyimportant behavioral, emotional,
psychological component to thesafety of oral immunotherapy
that cannot be ignored.
And this is not only in thepatient but also in, perhaps
(18:34):
more importantly, in thecaregivers.
Speaker 3 (18:38):
Yes, absolutely, absolutely, and I think that's a
good point to make.
Before we started the recording, we were talking about one of
our mutual colleagues.
One of our mutual friends,tamara Hubbard, and food allergy
counselor, and I just thinkthat the work that Tamara does
is so important and having foodallergy informed counselors is
(19:01):
very important.
We have one here at the WhiteInstitute of Food Allergy and so
if you're listening to this andyou're like, wait, there's a
food allergy informed counseloryes, a little link to that and
the show notes too.
Speaker 2 (19:13):
There's a whole directory.
Speaker 3 (19:16):
Yes, it's amazing and you're exactly right, like
having that improvement in thequality of life that comes with
doing oral immunotherapy.
But recognizing that startingin oral immunotherapy depending
on the kiddos age of course canbe very stressful for the kiddo
(19:37):
but or anxiety-provoking Ishould say.
But then for the parents makingthat decision it can be just
such a hard decision to make,especially given the potential
impact on activities, becauseoral immunotherapy does have
that that about hour before, twohours after not doing anything
that's raising the heart rate orthe body temp.
(19:57):
Which I want to get into thisdiscussion, just at least a
little bit about sublingualimmunotherapy, because
sublingual immunotherapy has amuch different safety window.
So talk to our listeners alittle bit about sublingual
immunotherapy and how its safetywindow is different in your
(20:21):
practice from that in oralimmunotherapy.
Speaker 2 (20:24):
Sure, so, as we know, oral immunotherapy is a way of
retraining the immune system totolerate an allergen that it is
currently overreacting to, andin oral immunotherapy we are
administering the food allergenvia the mouth to be swallowed
and digested and absorbed andexposed to the immune system
(20:47):
through the immune tissues inthe gut, particularly the small
intestine.
In sublingual immunotherapy weare using much lower doses of
allergen and instead of directlyswallowing a food, we are
delivering these tiny doses ofallergen to the immune cells
(21:11):
that reside in the mucosa underyour tongue, right there.
So there are cells white bloodcells, called dendritic cells
that reside in this space thathave the capacity to capture
allergen, take it back to thelocal lymph nodes and break it
down into tiny little pieces inthe process, and in those lymph
(21:33):
nodes these white blood cellswill present those pieces of the
allergenic proteins to otherwhite blood cells and start this
cascade of immunologiccrosstalk that eventually sends
a signal to the white bloodcells in the bone marrow to
trigger class switching and moveaway from an allergenic profile
(21:55):
and more towards tolerance.
And this happens on a very,very tiny level and it's the
cumulative exposure over timethat builds up that tolerance.
And as you build up toleranceto the tiniest amount, then we
increase the dose and increasethe dose and so on and so forth.
But because sublingualimmunotherapy is to a large
(22:17):
extent bypassing the lower partof the gut and it's using such
small doses, the risk ofreactivity is significantly
lower compared to oralimmunotherapy, which then also
means we can ease up on some ofour safety rules.
(22:37):
I still insist on baselinehealth optimization prior to the
initiation of sublingualimmunotherapy, just like I would
with oral immunotherapy.
So I'm not going to startsublingual immunotherapy in
somebody with horrible asthma,for example, unless I can get it
well controlled.
But once we begin, once healthis optimized and then we begin
(23:02):
sublingual immunotherapy, thesafety rules are more relaxed.
It doesn't mean they'renon-existent, but they're not
astringent.
So, for example, you don'tnecessarily need to have food in
your valley before you takesublingual immunotherapy.
You do not need to have as longof an exercise restriction and
(23:23):
some people might argue thatthere is no exercise restriction
required at all for sublingualimmunotherapy.
In my practice we still do onehour after.
That's speaking to ourconservatism.
But overall the risk of asystemic reaction or
anaphylactic reaction is muchlower in sublingual
(23:47):
immunotherapy than it is in oralimmunotherapy, even though the
dose, precisely because thedoses are so much lower.
And so of course then there'sthis concern will sublingual
immunotherapy give me the samelevels of protection as oral
immunotherapy?
(24:08):
And that can be a whole otherconversation, probably, but the
evidence is emerging that ifcontinued for long enough at
high doses for sublingualimmunotherapy, low compared to
oral immunotherapy, you canstill get really significant
levels of protection with longterm sublingual immunotherapy.
(24:31):
So it might be a very viabletreatment alternative for
patients who aren't goodcandidates for oral
immunotherapy or find theexercise restrictions associated
with oral immunotherapy to betoo cumbersome to follow long
term.
Speaker 3 (24:49):
I'll be excited.
Maybe we can repeat thisconversation in five years.
Oh yeah, just how much haschanged in five years?
Because right now I practicepretty much the same way as you,
which is fun to find out,because before this conversation
we hadn't talked very much atall.
So it'll be cool to see whereall this goes in the next five
(25:11):
years, because if we'd had thisdiscussion five years ago, it
would be a completely differentdiscussion, and so it's it's a
very exciting time I find toserve food allergy families.
Speaker 2 (25:26):
I think it's a great time to serve food allergy
Absolutely.
I tell my patients all the time.
If I had to be diagnosed with afood allergy in any decade, now
is the time.
Right Now is the time becausewe actually have things that we
can do to change the naturalhistory of the disease, and the
pace of advancement andinnovation in the food allergy
(25:50):
space is astounding.
Right now it seems like everyevery month I turn around and
there's some brand newdevelopment.
And you know, the nice thing isthere are multiple ways that
you can go about desensitization.
So of course, we have oralimmunotherapy, sublingual
(26:12):
immunotherapy, there will soonbe epi-cutaneous immunotherapy
down the road, intralemphaticimmunotherapy, perhaps oral
mucosal immunotherapy so manydifferent ways to introduce the
allergen into the body.
And the key is having expertisein all of these modalities and
not just one, so that when apatient comes to you you can put
(26:36):
the right patient on the righttreatment for them.
Speaker 3 (26:43):
I couldn't have said it any better.
Thank you so much for coming onthe podcast and talking about
this today.
I can tell already this isgoing to be a very downloaded
episode.
Speaker 2 (26:54):
It's my pleasure.
Thank you so much for having me.
Speaker 3 (26:59):
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
episode and visit us atfoodallergyandyourkiddocom,
where you can submit yourfamily's questions.
God bless you and God blessyour family.
Welcome to.
Speaker 1 (00:02):
Food Allergy and your Kiddo with Dr Alice Hoyt the
podcast about demystifying foodallergies, diminishing allergy
anxiety and taking back control.
Let's navigate this challengetogether with evidence-based
information, scientific researchand tried-improven practices.
And now here's your hostboard-certified allergist and
(00:24):
immunologist specializing infood allergy, Dr Alice Hoyt.
Speaker 3 (00:30):
Hello and welcome to the Food Allergy and your Kiddo
podcast.
I am your host, dr Alice Hoyt,over the moon excited about
today's guest.
Dr Sakina Bajawala is aboard-certified allergist and
pediatrician and she practicesin the western suburbs of
Chicago.
And Dr Bajawala you might knowher from her writings on Web Nd.
(00:53):
Also, she is one of thoseamazing docs involved in solid
starts that is all overInstagram helping new mamas and
papas be able to give theirkiddos age-appropriate food, but
not just mushy, mushy, mushyfood.
So I'm so excited to have youtoday, sakina.
(01:14):
Welcome to the podcast.
Speaker 2 (01:16):
Well, thank you, Alice, for having me.
I'm delighted to be here.
Speaker 3 (01:23):
Today, what I really want us to talk about is really
optimizing safety duringimmunotherapy, specifically oral
immunotherapy, sublingualimmunotherapy, the food
immunotherapies ordesensitization.
And so, if you're new to thepodcast and listening, we've had
lots of episodes one, what isoral immunotherapy?
(01:47):
I'll talk about what issublingual immunotherapy, but
today I really want us to focuson the safety of it all.
And so, dr Bajawala, when afamily first comes to see you
and you'll have the discussionabout desensitizing their kiddo
to a food, what are some ofthose first safety questions you
(02:11):
feel you're feeling the most?
Speaker 2 (02:15):
I would say the number one fear and concern that
families have when we broachthe subject of food allergen
desensitization is the risk ofanaphylaxis.
After all, for most families,the reason that they're even
considering food allergendesensitization in the first
(02:36):
place is they would like toavoid anaphylaxis in the future.
So many of them haveencountered literature or online
articles claiming that the riskof anaphylaxis from a food
allergen is actually increasedduring food allergen
(02:56):
desensitization compared tostrict avoidance, and that, of
course, is concerning to them,and so they're always asking if
the whole point of this is toavoid anaphylaxis and there's an
increased risk of anaphylaxisduring food allergen
desensitization, what are wedoing here at all, and what are
you going to do to minimize mychild's chances of experiencing
(03:20):
such a reaction, and what can Ido as a parent to do the same?
Speaker 3 (03:26):
And how do you answer that very specific, yet very
common, super common question?
Speaker 2 (03:35):
Yeah, I would say.
Well, the first thing I do isexplain the difference between
overall incidence of anaphylaxisduring a course of
immunotherapy and compare thatto the risk of anaphylaxis as a
(03:59):
function of the number ofexposures, right?
So when you're comparing howoften someone might experience
an allergic reaction and usethat as the numerator of a
fraction and then divide that bythe number of exposures during
that time period as adenominator, that ratio is more
(04:23):
reflective of how effectiveimmunotherapy is.
So in the event of strictavoidance, that ratio is higher
than what you would see duringthe course of food allergen
desensitization.
And the reason as a function ofnumber of exposures, the rate
(04:45):
of anaphylaxis is relatively lowduring oral immunotherapy is
because, as allergists, we areworking very hard to optimize
baseline health prior to theinitiation of treatment.
So we think about this conceptof a bucket that holds your
(05:06):
allergic inflammation.
And there is only so muchinflammation that this bucket
can hold before it overflows andsays I give up, I'm going to
have a reaction, right.
And so many different thingscontribute to this bucket.
If you have uncontrolled eczema, that fills the bucket up a
little bit.
If you have poorly controlledasthma, it fills the bucket a
(05:30):
little bit more.
If your environmental allergiesare very, very active.
The bucket is further still.
And then, on top of that, ifyou introduce daily exposure to
a food allergen, you have verylittle space left in that bucket
before it overflows.
Now, if you focus instead onnot being so intent on starting
(05:59):
food allergen desensitization assoon as possible, but rather
take your time and empty thatbucket out Right, so get asthma
under control, get eczema undercontrol, get your environmental
allergies under control.
If there's any constipationissues, get that under control,
(06:19):
all of a sudden the level of thebucket is down here and now you
have more wiggle room to put afood allergen in on a regular
basis with a total overflowing.
So that is job number oneOptimizing baseline health, and
it's enormously important to thesafety of immunotherapy long
term.
Speaker 3 (06:40):
Love that, love that, especially, I would say, with
our asthmatic kiddos and reallymaking sure that, even if they
have what you think is maybemild intermittent asthma, but
then really doing a good deepdive into how much asthma is
(07:01):
that kiddo having, how manytimes is that kiddo wheezing or
coughing with a viral infectionor with allergen exposure, and
really optimizing that asthmaregimen, even sometimes starting
an inhaled corticosteroidsooner than maybe you would if
they weren't starting OIT.
Maybe you try singular, maybeyou try optimizing something
(07:25):
else or a little bit heavier onthe, on the antihistamine or
nasal spray or whatever you wantto do to minimize the allergen,
the allergy load, I guess Iwould say.
But I find that I am now muchquicker to try to optimize,
especially asthma, definitelyeczema, definitely seasonal
(07:47):
allergies, but especially asthma.
I agree.
I especially sense with asthma.
We do not want an asthma, wedon't want an asthma reaction.
We don't ever want, I don't everwant, I don't think you ever
want the lungs involved in theseanaphylactic reactions or these
even mild reactions that thencould potentially be worse than
(08:10):
when you're doing every day atrisk of having an allergic
reaction.
The other thing that I like tothink about with OIT and
optimizing safety is really andsort of the numerator-genomic
discussion that you were talkingabout is thinking about when
(08:35):
somebody is having an ingestionof their allergen.
If they're on an avoidancepathway meaning that they're not
on OIT or slit and they have anaccidental ingestion and they
have a reaction.
That's gonna be a completelydifferent anaphylactic situation
than when you're doing oralimmunotherapy and you know that
(08:55):
you're giving your child a veryparticular amount of a very
specific allergen and you havethat safety window, especially
with OIT, with slit, we can talka little bit about the safety
with slit, since it has such abetter safety profile regarding
the daily dosing and the safetywindow, as I call it.
(09:17):
But really just a reaction thatyou have with OIT is gonna be
just so much.
It's a much more controlledenvironment than heaven forbid
those calls that we get frommoms when their kiddo has an
accidental ingestion ofsomething at school and they
don't know how much of it it was, or if it's a kid with multiple
food allergies, they don't knowwhich allergen it was.
(09:39):
And those reactions, with somany unknowns, I feel like they
just weigh so much more onfamilies than the potential of
the OIT reactions Is that sortof in your experience.
Speaker 2 (09:54):
Absolutely right.
The difference betweenanaphylaxis out in the field
versus during oral immunotherapyis that in oral immunotherapy
you have a precise dose underoptimized conditions, under
supervision and so you need toRight and I'm gonna stop you
(10:15):
right there to make sure ourlisteners understand optimized
conditions.
Speaker 3 (10:20):
Whenever we're doing oral immunotherapy especially
for new to the podcast wheneverwe're doing oral immunotherapy
with a family, we give themparameters by which to either
contact us or absolutely do notdose, such as if you're having a
fever, if your kiddo is havinga fever, who's doing the OIT
right, vomiting out in the heat,which I know right now across
(10:43):
the country.
It's just been madness.
So anything that's raising thebody temperature, increasing the
heart rate, those are gonnalower the threshold to have an
allergic reaction.
And so, sakina, I mean you'rehitting the nail on the head.
It's we are under optimalconditions when we're doing OIT.
And one little tangent sometimesif you're not a new listener
(11:07):
then you know that sometimestangents occur on this podcast.
Many times when we havereactions with OIT it is because
there has been an oops.
You're right, he had a feverearlier and I gave Tylenol.
Then I totally forgot, or hehit his arm and so I gave him a
(11:28):
motrin and I totally forgot thatmotrin can lower the threshold
and that I'm supposed to callyou about that or hold the dose.
So definitely those confoundersthat happen.
But yeah, I think we see thesame thing about the.
When a reaction is happeningduring OIT, it's just such a
different, it's just a differentsituation than when it's
(11:49):
happening in the field.
Speaker 2 (11:51):
Yeah, and it can be really easy for families to get
a little bit complacent afterthings have been going very well
for a long time.
So of course we give theprinted out list of safety rules
and of course we have 24-7availability to answer questions
(12:11):
related to oral immunotherapydosing, because I would much
rather that a family reach outto me at 6.30 in the morning and
ask me a question so I can sayyou know what you need to skip
your dose today, rather thanworry that they're going to
bother me and then just say, oh,it probably is fine, I don't
(12:35):
want to call her, give the dose.
And then they got to call meanyway because the kids needing
any Right, right.
So I always say I will never beupset, my step will never be
upset if you call me with aquestion, and so we get a lot of
questions, right.
And so one of the things westarted doing is we realized
that our safety rules apply toall of our patients.
(12:58):
Right, we have a protocol, mycolleagues have protocols, you
have internal protocols and forthe most part our safety rules
as an oral immunotherapycommunity are pretty uniform.
They may not be exactly thesame, but conceptually they're
the same.
We want to make sure that thedose is administered not on an
(13:22):
empty stomach, without a fever,without active illness, without
active asthma symptoms.
We want to control the heartrate and the core body
temperature around dosing time.
We want to make sure that thosefactors that might increase the
risk of having a reaction arecontrolled for so I don't want
(13:44):
kids dosing late at night.
I don't want kids dosing whentheir routine has been
completely disrupted, or if theyhad a horrible night of sleep
and they're exhausted, or ifthey've been out all day.
Speaker 3 (13:57):
Cut out a little bit, but I think what you said is
that you don't want them dosingwhen their routine has been
interrupted and they'reexhausted and sleep deprivation.
Speaker 2 (14:06):
Yeah, we actually have data in peanut allergy
showing that sleep deprivationand dehydration are associated
with an increased risk of peanutanaphylaxis and we can
extrapolate from the data aboutpeanut to making safety rules
(14:26):
for the deliberate exposure ofpeanut and other food allergens
in these patients.
So, knowing that all of us havethese very similar and somewhat
standardized safety rules,we've tried to integrate that
into our protocol.
So we have all of our patientslike log their doses regularly
(14:48):
and there are screeningquestions that pop up.
Before they log their dosesthey say in the last 24 hours,
have any of these thingsoccurred?
If they have, they click a boxand it tells them you need to
reduce your dose or you need toskip your dose today.
Speaker 3 (15:03):
You have an app for that right.
What is the name?
Of your app.
Speaker 2 (15:07):
The app is called the Food Allergy Fix Mobile App.
Speaker 3 (15:11):
Nice, nice.
We'll put a link to that in theshow notes.
That's awesome.
Speaker 2 (15:17):
And you know these rules are things that most
allergists are doing anyway,right?
They're giving it to theirpatients.
So pretty much all patients arebeing asked to follow very
similar rules and, like I wassaying earlier, it can be easy
to fall out of the habit oncethings have been going well for
a while.
So what you mentioned earlier,Alice, those oops moments Pretty
(15:41):
much any time there'sanaphylaxis, when we debrief and
look backwards, we find thatoops moment right, and I think
that's probably your experienceas well.
Speaker 3 (15:52):
Yes, it is, and it's reassuring, right?
It's reassuring that for themost part, kiddos do very well
with oral immunotherapy.
For the most part that there'snot necessarily a lot of big
surprises along the way if we'refollowing a good protocol for
(16:15):
that patient.
I know that I am.
I would say I'm very proactiveallergist, but I'm also very
conservative, and what I loveabout being in my practice is
that I'm not confined by anysort of research protocol.
Right, because the horse is outof the barn like, oh I teamwork
, right, we don't need aresearch protocol for it.
(16:38):
It was nice about it inparticular is that if a mom says
you know what, she just reallyhasn't been feeling.
Well, do you think we should updose Like she doesn't have a
fever or anything?
But I'm like, nope, let's waittill next week.
Speaker 2 (16:51):
That's always air on the side of caution, and I think
most allergists will do that,because it is not a race, it's a
marathon.
Speaker 3 (17:00):
Slow and steady and it's not a race.
Speaker 2 (17:02):
It's not a race, it doesn't matter how fast you get
to the finish line, it justmatters that you're still in the
running.
And I am just like you.
If I get that call I'll say,yeah, skip, it's fine, we'll get
back on track tomorrow.
And people are so stressed I'mlike, oh, but if I miss a day
(17:25):
I'm going to throw everythingoff.
And no, you're not.
I have some patients who missed,for I mean, during the peak of
the COVID pandemic, when peoplewere getting COVID right and
left, I had patients who weresymptomatic with their illness
and they were missing their dosefor seven, 10 days at a time.
And they didn't have to startall over, we just took them back
(17:48):
a little bit, brought them intoclinic, made sure they could
tolerate a slightly reduced doseand built them back up.
And I think having a sense ofreassurance and calm and
trusting the process is veryimportant because you know we've
talked about the organic andphysical aspects of health
(18:12):
optimization in safetyoptimization prior to oral
immunotherapy.
But there's a really, reallyimportant behavioral, emotional,
psychological component to thesafety of oral immunotherapy
that cannot be ignored.
And this is not only in thepatient but also in, perhaps
(18:34):
more importantly, in thecaregivers.
Speaker 3 (18:38):
Yes, absolutely, absolutely, and I think that's a
good point to make.
Before we started the recording, we were talking about one of
our mutual colleagues.
One of our mutual friends,tamara Hubbard, and food allergy
counselor, and I just thinkthat the work that Tamara does
is so important and having foodallergy informed counselors is
(19:01):
very important.
We have one here at the WhiteInstitute of Food Allergy and so
if you're listening to this andyou're like, wait, there's a
food allergy informed counseloryes, a little link to that and
the show notes too.
Speaker 2 (19:13):
There's a whole directory.
Speaker 3 (19:16):
Yes, it's amazing and you're exactly right, like
having that improvement in thequality of life that comes with
doing oral immunotherapy.
But recognizing that startingin oral immunotherapy depending
on the kiddos age of course canbe very stressful for the kiddo
(19:37):
but or anxiety-provoking Ishould say.
But then for the parents makingthat decision it can be just
such a hard decision to make,especially given the potential
impact on activities, becauseoral immunotherapy does have
that that about hour before, twohours after not doing anything
that's raising the heart rate orthe body temp.
(19:57):
Which I want to get into thisdiscussion, just at least a
little bit about sublingualimmunotherapy, because
sublingual immunotherapy has amuch different safety window.
So talk to our listeners alittle bit about sublingual
immunotherapy and how its safetywindow is different in your
(20:21):
practice from that in oralimmunotherapy.
Speaker 2 (20:24):
Sure, so, as we know, oral immunotherapy is a way of
retraining the immune system totolerate an allergen that it is
currently overreacting to, andin oral immunotherapy we are
administering the food allergenvia the mouth to be swallowed
and digested and absorbed andexposed to the immune system
(20:47):
through the immune tissues inthe gut, particularly the small
intestine.
In sublingual immunotherapy weare using much lower doses of
allergen and instead of directlyswallowing a food, we are
delivering these tiny doses ofallergen to the immune cells
(21:11):
that reside in the mucosa underyour tongue, right there.
So there are cells white bloodcells, called dendritic cells
that reside in this space thathave the capacity to capture
allergen, take it back to thelocal lymph nodes and break it
down into tiny little pieces inthe process, and in those lymph
(21:33):
nodes these white blood cellswill present those pieces of the
allergenic proteins to otherwhite blood cells and start this
cascade of immunologiccrosstalk that eventually sends
a signal to the white bloodcells in the bone marrow to
trigger class switching and moveaway from an allergenic profile
(21:55):
and more towards tolerance.
And this happens on a very,very tiny level and it's the
cumulative exposure over timethat builds up that tolerance.
And as you build up toleranceto the tiniest amount, then we
increase the dose and increasethe dose and so on and so forth.
But because sublingualimmunotherapy is to a large
(22:17):
extent bypassing the lower partof the gut and it's using such
small doses, the risk ofreactivity is significantly
lower compared to oralimmunotherapy, which then also
means we can ease up on some ofour safety rules.
(22:37):
I still insist on baselinehealth optimization prior to the
initiation of sublingualimmunotherapy, just like I would
with oral immunotherapy.
So I'm not going to startsublingual immunotherapy in
somebody with horrible asthma,for example, unless I can get it
well controlled.
But once we begin, once healthis optimized and then we begin
(23:02):
sublingual immunotherapy, thesafety rules are more relaxed.
It doesn't mean they'renon-existent, but they're not
astringent.
So, for example, you don'tnecessarily need to have food in
your valley before you takesublingual immunotherapy.
You do not need to have as longof an exercise restriction and
(23:23):
some people might argue thatthere is no exercise restriction
required at all for sublingualimmunotherapy.
In my practice we still do onehour after.
That's speaking to ourconservatism.
But overall the risk of asystemic reaction or
anaphylactic reaction is muchlower in sublingual
(23:47):
immunotherapy than it is in oralimmunotherapy, even though the
dose, precisely because thedoses are so much lower.
And so of course then there'sthis concern will sublingual
immunotherapy give me the samelevels of protection as oral
immunotherapy?
(24:08):
And that can be a whole otherconversation, probably, but the
evidence is emerging that ifcontinued for long enough at
high doses for sublingualimmunotherapy, low compared to
oral immunotherapy, you canstill get really significant
levels of protection with longterm sublingual immunotherapy.
(24:31):
So it might be a very viabletreatment alternative for
patients who aren't goodcandidates for oral
immunotherapy or find theexercise restrictions associated
with oral immunotherapy to betoo cumbersome to follow long
term.
Speaker 3 (24:49):
I'll be excited.
Maybe we can repeat thisconversation in five years.
Oh yeah, just how much haschanged in five years?
Because right now I practicepretty much the same way as you,
which is fun to find out,because before this conversation
we hadn't talked very much atall.
So it'll be cool to see whereall this goes in the next five
(25:11):
years, because if we'd had thisdiscussion five years ago, it
would be a completely differentdiscussion, and so it's it's a
very exciting time I find toserve food allergy families.
Speaker 2 (25:26):
I think it's a great time to serve food allergy
Absolutely.
I tell my patients all the time.
If I had to be diagnosed with afood allergy in any decade, now
is the time.
Right Now is the time becausewe actually have things that we
can do to change the naturalhistory of the disease, and the
pace of advancement andinnovation in the food allergy
(25:50):
space is astounding.
Right now it seems like everyevery month I turn around and
there's some brand newdevelopment.
And you know, the nice thing isthere are multiple ways that
you can go about desensitization.
So of course, we have oralimmunotherapy, sublingual
(26:12):
immunotherapy, there will soonbe epi-cutaneous immunotherapy
down the road, intralemphaticimmunotherapy, perhaps oral
mucosal immunotherapy so manydifferent ways to introduce the
allergen into the body.
And the key is having expertisein all of these modalities and
not just one, so that when apatient comes to you you can put
(26:36):
the right patient on the righttreatment for them.
Speaker 3 (26:43):
I couldn't have said it any better.
Thank you so much for coming onthe podcast and talking about
this today.
I can tell already this isgoing to be a very downloaded
episode.
Speaker 2 (26:54):
It's my pleasure.
Thank you so much for having me.
Speaker 3 (26:59):
That's the episode.
Thanks so much for tuning in.
Of course I'm an allergist, butI'm not your allergist.
So talk with your allergistabout what you learned on this
episode and visit us atfoodallergyandyourkiddocom,
where you can submit yourfamily's questions.
God bless you and God blessyour family.
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