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Oral immunotherapy (OIT) has revolutionized the way we manage food allergies in children. Join Dr. Alice Hoyt as she interviews Dr. Richard Wasserman, a true pioneer in this groundbreaking treatment.
Dr. Wasserman shares his journey on how and why he started offering OIT to patients over 15 years ago. Dr. Hoyt and Dr. Wasserman discuss the history of OIT and its similarities to allergy shots. They also emphasize the importance of collaboration among allergists to make life-changing therapies more accessible worldwide.
OIT presents unique challenges across different age groups, and this conversation sheds light on these nuances. With relatable analogies like gym workouts, Dr. Wasserman and I talk through the adjustments necessary to maintain tolerance without overwhelming the patient. From the unique challenges faced by children and teens at different ages to potential family conflicts, this episode offers practical insights for managing food allergies over the long run, helping both the patient and the patient's family feel supported every step of the way.
Dr. Hoyt asks Dr. Wasserman to share his experiences on helping families navigate the myriad challenges that come with OIT, from the impact of illnesses on dosing schedules to the necessity of avoiding certain activities post-dosing. Dr. Wasserman shares his thoughts on the FDA-approved peanut allergy product and shares about his team's efforts to ease the journey of peanut OIT for kids. Concluding on a high note, Drs. Hoyt and Wasserman celebrate the immense relief and joy that OIT brings to many families, many times enabling children to safely consume previously dangerous allergens. Don't miss this opportunity to hear from a true trailblazer in the field of food allergy management!
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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 1 (00:05):
Hello and welcome to Food Allergy and your Kiddo.
I am your host, dr Alice Hoyt,over the moon, super excited to
be joined today by Dr RichardWasserman.
For those of you who have everlooked up OIT or wondered about
oral immunotherapy, chances areyou have come across Dr
(00:27):
Wasserman.
Dr Wasserman is one of thepioneers who has taken OIT and
made it what it is today, whichis significantly more accessible
to families, not just acrossthe country but literally across
the globe.
Dr Wasserman's academicaccolades are outstanding.
(00:49):
He is board certified inallergy and immunology and in
pediatrics.
His medical degree is fromMount Sinai, also UT
Southwestern.
He did pediatrics residency atChildren's Hospital of
Philadelphia, fellowshiptraining bone marrow transplant
immunology at Children'sHospital of Philadelphia,
postdoctoral cancer immunologyUniversity of Texas,
(01:11):
southwestern and immunologyrheumatology, rockefeller
University.
He has a PhD in biomedicalsciences from University of New
York, mount Sinai.
I mean um?
And then when you go to PubMedand look for Wasserman, see he's
so popular, someone's callinghim right now because of his
(01:33):
expertise and his brilliance.
That's totally fine.
Oh my gosh.
Um, I'm not surprised someone'scalling you and it's probably
somebody calling you with an OITquestion because you have
really made this amazing therapythat helps kids and adults be
significantly less allergic tofoods much more available to
(01:56):
these tens of thousands,hundreds of thousands, arguably
millions of patients.
So thank you very much forjoining us today to really talk
about oral immunotherapy.
Speaker 2 (02:09):
Thank you very much for having me.
It's a pleasure to be speakingto you this afternoon and I just
have to react to yourintroduction by saying that I've
been in medicine for a verylong time and when I grew up in
medicine, doctors were notinterested in patents and
startups.
They were interested in sharingwhat they knew for the
(02:34):
betterment of the medicalprofession and patients, and
that has been my North Star inmy practice and the activities
that I've been involved with,particularly in food allergy
treatment.
Speaker 1 (02:48):
And that really shines through, through not just
your words but literally youractions.
And that's a lot of what we'lltalk about in the interview,
(03:09):
about in the interview.
But just to sort of dive rightin, what is oral immunotherapy
For our listener who is tuningin maybe for the first or second
time and say, hey, I've heardthat name Wasserman before.
Something about OIT.
How do you introduce OIT?
Speaker 2 (03:19):
is one of the ways of retraining the body's allergy
system so that a food in thissituation, a food that causes a
problem becomes acceptable tothe child or adult with food
(03:40):
allergy, and it's one of severaltherapies that lead to what's
referred to as desensitization,which just means reducing the
sensitivity level that peoplehave to their allergenic food,
and it's really very similar toallergy shots.
(04:03):
It's, in fact, it's about as oldas allergy shots.
Allergy shots are almost 120years old and the first reports
of food therapy date back toearly in the last century, but
it's kind of lost to history fora while.
There was a report in 1935 in amajor allergy journal, but
(04:27):
nobody appeared to reallyproduce it.
And when I met Dr LyndonMansfield from El Paso, who I
had known before at a meetingalmost 20 years ago, and he told
me that he had treated a coupleof peanut-allergic patients
(04:48):
with oral immunotherapy and thatit had worked out well, I was
somewhat startled and just veryenthusiastic.
He was generous and shared hisprotocols with me, and I spent
about two years reviewing thefield and the available
literature and then we startedin the summer of 2008 with our
(05:15):
first treatment of patients withegg and milk allergy, which is
kind of interesting inretrospect, because I chose milk
and egg because I was afraid ofpeanut and it turns out that
for most people peanut's a loteasier than milk and egg.
(05:36):
So we've learned a lot in thepast 15 plus years.
Speaker 1 (05:43):
Oh, that's amazing.
That's amazing, that's amazingand that really speaks to, in
part, the culture of allergistsand the culture of what medicine
I believe needs to be, which isallergists talking to each
other and learning from eachother and sharing with each
other what works, what doesn'twork, what experience they've
had.
Absolutely, we lean intojournals and and big studies and
(06:05):
that is absolute.
Those are absolutely important.
But there's also so much wisdomin talking to others and
talking to those who have comebefore us and have experiences
that aren't necessarilydocumented or maybe it's a few
case reports here or there toreally continue to move the
(06:26):
field forward and in a way thatis you know, I keep using the
word accessible but isaccessible to families so many
times when something goesthrough a big clinical research
trial and clinical researchtrials are incredibly important
and they validate and it's justincredibly important.
Trials are incredibly importantand they validate and it's just
incredibly important, butsometimes, as you know, it can
take 10 plus years for thosefindings to really get
(06:49):
implemented into practice.
But in this day and age, whenwe can continue to have
conversations and share justlike we do with the OIT advisors
listserv sharing cases, toughcases, what worked, what hasn't
worked.
It's so helpful.
And it's helpful especially Iwill say personally and talk a
(07:09):
lot about myself on this podcast, but I would say from a
professional standpoint in mypractice I love being able to
talk, to hear your opinions onclinical cases through our email
list server.
We have hundreds of allergistsin the trenches with oral
immunotherapy, sublingualimmunotherapy, complex difficult
(07:29):
food allergy.
But because we're able to talkto each other and learn from
each other and kind of you know,you hit the nail on the head
with how you kind of spoke aboutwhat I call your spirit of
sharing information and thatthat's what medicine needs to be
about.
You know I mean God bless youBecause of all before we came on
(07:50):
.
What I told you is because ofthe work you have done.
You have allowed me and otherallergists like me to offer more
therapies to patients and it'samazing.
It's amazing and you know Ilove that you talked to him
about the history of oralimmunotherapy and that it's
amazing.
It's amazing and you know Ilove that that you talked some
about the history of oralimmunotherapy and that it's it's
it's not necessarily this supernew novel concept that it
(08:12):
really is very similar toallergy shots that we have been
doing for a very long time thatwe know work.
We know that if you slowlyintroduce an allergen to the
system, that over time it willteach the immune system in many
cases to become more tolerant toit.
So that's amazing that that'show you started it.
(08:36):
Tell me a little bit more aboutsort of the first time in your
practice.
And were you in privatepractice then?
Yes, nice.
And were you in privatepractice then, yes, nice.
And so you had a little bitmore control over how your
practice integrated new servicelines.
I would say is a nicediplomatic way to talk about
(08:59):
trying new things.
And how did the familiesrespond?
Speaker 2 (09:01):
Well, there was pent-up demand.
Well, there was pent-up demand.
(09:30):
People were looking forsolutions and you know I knew
the first and that was about1,200 patients ago.
So there's been a lot, a lothas gone on.
And your point about experienceand taking advantage of that I
think it's important for peopleto understand that doctors
shouldn't go down the gardenpath based on one experience,
but they need to be aware oftheir experience and we
(09:53):
collected our experience.
We have a spreadsheet of 120columns and now 1,200 rows of
all the patients we've evertreated and, even though they
weren't formal controlled trials, when you analyze that
(10:15):
information you can learnimportant things and one of the
differences between thoughtfulclinical practice and a research
trial In a research trial, thetrial is designed to answer
specific questions that are laidout in advance in a very rigid
way and participation in thattrial is very rigid.
(10:40):
There's not flexibility ofdosing or timing or other things
in order to get the purestanswer to the question.
But we embarked on treatmentand in treatment you learn from
your patients in what we do overthe years, by paying attention
(11:06):
to our patients and learningfrom them and using that
collected experience to thenapply that to the next round of
patients and hopefully get aneasier treatment with fewer side
effects and better outcomes.
Speaker 1 (11:24):
That's amazing.
I mean, that's what I thinkpatients hope we're always doing
is being mindful and verythoughtful and specifically
especially if it's a littlekiddo that we are thinking about
that particular childspecifically and trying to apply
(11:44):
the best possible evidence andexperience that we have to make
that child's treatment plan thebest treatment plan for that
child.
Speaker 2 (11:57):
Data is crucially important, but you and I take
care of patients one at a time,and it's the other person in the
examining room who is the focusof everything that came before
that person and applying thatknowledge.
Speaker 1 (12:17):
Oh my gosh, that's so good.
So it sounds like in thebeginning it was fairly well
received understatement.
People wanted it, of course.
Even to this day I havepatients coming in saying there
has to be more than just carryan EpiPen.
There has to be more, there hasto be more.
And I say, well, yes, there ismore.
And then we talk about things.
(12:38):
So what are some of the biggest, I would say, misconceptions
when a family first comes in andthey've heard something about
OIT, but what are some of thebiggest misconceptions that you
hear from families?
Speaker 2 (12:56):
I think the big misconceptions are that it is a
relatively short-term treatment.
So there's a lot of data aboutallergy shots that says, after
an appropriate course of allergyshots that last three to five
(13:20):
years, you can stop the shotsand the progress you've made is
enduring.
We don't have that kind of datafor OIT In fact the best
evidence because I see it atthis point says that at some
level people who are successfulin OIT need to continue eating
(13:41):
that food on a regular basis,not necessarily every day, but
indefinitely.
And so I think, even though wemake a big deal of the fact that
there needs to be indefinitedosing, when people reach
certain milestones along the wayin their treatment.
(14:07):
People reach certain milestonesalong the way in their treatment
they're inclined to think that,to say, well, now I'm cured and
I don't have to think about itand it's really.
For at least at this point,it's not correct to say that any
kind of food therapy is a cure,and food therapy can bring a
(14:28):
patient into a remission and theremission can last a very long
time without any problem.
So if someone is treated forpeanut or milk or egg or
something more exotic and istreated successfully and
maintains their treatment for aperiod of time and gradually has
(14:51):
a decreasing need for regulardosing, we still hold them on
dosing no less than once a weekindefinitely to maintain that
remission.
And I think, even though wetalk about that in the beginning
and the middle and further on,it's still kind of a surprise to
(15:11):
many families that it'sindefinite Now.
In the past several years,others and we have started
treating very young children.
In our first several hundred OITpatients we limited the lower
(15:32):
age to four years, but thenthere were reports of success
with younger children and now wewill start as young as six
months and now we will start asyoung as six months and some of
those very young children whojust had one reaction that was
(15:55):
not a bad reaction and whosetests are very weakly positive,
we may challenge them to be surethat they actually have a
reaction and then we treat themand their allergic antibody
disappears Some of them.
They go to zero, and exactlywhat's going to happen with
those children over time isunclear.
(16:18):
They may in fact have a cure.
Fortunately, there's reallygood research being done looking
at more detailed and specifictests that will tell us exactly
what's going on.
Right now we don't know for surewhether a treated patient is
(16:40):
the same as one who has outgrowntheir food allergy.
Is the same as one who hasoutgrown their food allergy?
So somebody who was allergic tomilk at age three and is now
age eight and passes the milkchallenge and is no longer
allergic, is that the sameperson allergically as somebody
who started OIT at age three andhas been drinking milk without
(17:04):
thinking about it since age fouror five at age eight?
Are they the same?
We don't know that yet, but Ithink that there are studies in
progress and very interestingtranslational research that's
looking at studies that are notused in clinic lab tests that
(17:25):
are really not availablegenerally to you and me?
That may answer that question.
I think that's one of the,perhaps one of the next
revolutions that will come downthe line.
Speaker 1 (17:39):
That will be very nice.
Yeah, I look forward to that.
What do you tell patientsregarding after they go through
buildup and they're onmaintenance and then they have
that negative ingestionchallenge so say they're eating
half a teaspoon of peanut butterfor their maintenance and then
they do a full two tablespoonchallenge and they started when
(18:00):
they were a couple of years oldI talk about.
Now you're in tolerancepreservation phase and we have
to balance out how much peanutyou need to eat to keep that
tolerance that you've built.
Kind of like you go to the gymand you've built up where you
want to be.
Well, you can't be that gazelleintense forever, right?
So you're going to kind of stepback from the gym but you still
(18:20):
want to preserve the greatprogress that you've made and
the immune system is similar,right?
So what are you seeingclinically in patients when
they're young, or maybe whenthey're in that kindergarten
third grade age, when they startOIT?
Some of the differences betweenthe early childhood and the
(18:41):
mid-childhood and even teens forwhen they start and then what
really does after maintenancelook like for them Are a lot of
them getting into, kind ofleaving it in the rearview
mirror?
I know like in my practice.
A lot of the younger kids likeit's super exciting, right?
Working with the younger kidsis awesome because we do see
(19:01):
some really promising signs thatthis is something they're not
going to have to worry about athigh school graduation.
So talk a little bit more aboutwhat sort of anticipatory
guidance you give families onwhat to expect after maintenance
.
Like, are they going to bedrinking milk every day and
going for a run, but stillmaking sure that they're doing
something at least once a week?
(19:22):
What's sort of your guidance?
But still making sure thatthey're doing something at least
once a week?
What's?
Speaker 2 (19:25):
sort of your guidance .
Well, I'm going to put theexercise issue on the side for a
minute.
Sure, To focus on the otherpart of your question.
It depends on the nature of thefood, For what I would refer to
(19:45):
as staple foods basically milk,egg and wheat, or in some
cultures it may be soybeans orchickpeas or even cashew nuts.
That are a part of some dietswhere there's going to be a
routine, frequent exposure.
A fair number of our patientsrely on their routine daily
(20:07):
consumption for theirmaintenance dosing at some point
.
Speaker 1 (20:14):
And do you still have them have?
I'm sorry to interrupt you doyou still have?
Them eat that within a safetywindow or over time?
Do you allow that guardrail tocome down?
Speaker 2 (20:24):
Well, some patients just take it down and tell me
later.
You know I hate making peoplesick and I hate reactions, and
so I, and when we started, therewas a lot more unknown and just
a great unknown.
A lot more unknown and just agreat unknown, and all of us who
(20:48):
were involved in OIT werereally nervous about the risk of
a severe reaction or gotcommitted death, and so we use
very high doses for maintenance.
What we know now is that thedoses that we use for
(21:11):
maintenance are probably higherthan they need to be, and we're
working on reducing maintenancedoses and frequency.
When we started, we demandedthat people dose seven days a
week for a minimum of threeyears, and we've modified that
(21:32):
considerably over time and we'restill learning.
These are kinds of questionsthat are answered by collective
experience.
Nobody's going to do a researchtrial comparing three years of
(21:53):
six out of seven days a weekdosing with one year of six out
of seven and two years of fourout of seven.
Nobody's ever going to do thatstudy Right.
Four out of seven Nobody's evergoing to do that study Right.
And so you just need to payattention to what patients tell
you and put together thatexperience and in a conversation
with families, explain.
(22:14):
You know, the data is clearthat the higher your daily dose
and the more you give, thebigger.
The more frequently you give it, the bigger the impact on your
allergy testing.
There's no question about that.
But how much of it is overkill,you know?
(22:37):
If you know that you can givesomebody 40 peanuts a day for
five years and theirdesensitization is likely to
last six months, is that reallymeaningful and valuable Right?
Wouldn't it be easier to havethem eat four peanuts a day?
Right, four days a week or twodays a week and go from there?
Speaker 1 (23:04):
Especially depending on their age.
Speaker 2 (23:06):
Yes, and some families would opt for the
higher, more frequent doses.
I have families who don't wantto cut back at all because
they're nervous about that.
But you know, when you start itmakes a big difference.
(23:26):
So the very young, infants andtoddlers there's much less
problem with getting them totake the dose and the food.
It's unusual to have an infantor a toddler refuse a dose or
make it hard, whereas in the 6to 12 age group it's food
(23:50):
aversion and resistance todosing is a much more common
problem.
They get bored with the dose,even if it's not that they
dislike the food.
They get bored with having todo it every day and that's very
understandable.
For teenagers it's a whole otherissue, especially because most
(24:16):
teenagers have gotten used toavoiding their food by that time
.
And there's often a mismatchbetween the parent and the child
, and the parent wants to do OITand the child at best has no
interest and often has an activeinterest in not doing it.
(24:39):
And so one of the things we hadtalked about is who's a good
candidate and who's not a goodcandidate, and I would say that
children over the age of 10 or12 have to really be committed
to wanting to do it and we havesome kids who are really
committed and want to do it.
(24:59):
But if I don't get that vibe, Iwill kind of stop the OIT
conversation and say you know,we really can't go any further
unless your child is reallymotivated to want to do this.
You're going to have enoughopportunities to fight with your
(25:21):
teenager without giving youanother one, and I definitely
don't want to make conflict inyour household for the next six
years.
And a common response to that iswell, I'm worried about what
happens when they go to college,and my answer to that is you
(25:43):
only have the illusion ofcontrol.
Now, when they start driving, orcertainly when they go to
college, the illusion will begone and, regardless of what you
say, they're going to do whatthey want to do, and so I'm
completely satisfied.
(26:04):
If a four-, five-, six-year-olddoes OIT and has a normal life
and then, at age 16, decidesthey want to stop dosing Not my
(26:26):
recommendation recommendationbut if that child has had 10
years of going to birthdayparties and eating the cupcakes
and everything at school and nothaving to sit at the peanut
table and is able to go tosleepovers and then, at age 16,
decides they don't want to doseanymore, I can live with that,
and we talk about strategies forcollege for those kids who want
(26:48):
to continue their OIT dosing.
Hopefully we get them to once aweek by then, which gives them
a lot of flexibility, becausethe safe dosing rules, which I'm
sure you tell everybody aboutwe all do are really important
and they stay important, couldyou?
Speaker 1 (27:06):
talk a little bit about that now, about safe
dosing rules.
Yeah, even when they go tocollege they're still important.
Speaker 2 (27:13):
So we know there are some things that increase the
risk of a reaction.
The most straightforward ofthem are sickness Viral
infection is the biggest butinfections in general that
stress the body.
So when a child gets sick we'llcut their dose in half for
(27:35):
several days until they getbetter and then we gradually go
back up.
Some practitioners stop dosingwhen they're sick.
We haven't found a need to dothat.
We just cut the dose in halfand that works pretty well.
The other big factor isphysical activity, and for most
children vigorous aerobicphysical activity within two
(27:59):
hours of dosing is a significantrisk for reaction.
There is the rare and Iemphasize rare child who needs a
three or four-hour window afterdosing.
That happens but it's very rare.
So you want to do that.
(28:19):
And that thing that a lot offamilies have trouble
remembering is that dosing after8 o'clock at night increases
the risk of a reaction.
So you're better off skippingthat day's dose.
If the family's been out, youcan't dose until 9 or 10 at
night.
You're better off skipping thatday.
(28:40):
That's what we recommend.
Speaker 1 (28:43):
Can you talk a little bit about why that is?
Speaker 2 (28:46):
Well, all people make steroids inside their body and
the production of steroids inthe body is circadian.
That means it follows a 24-hourclock and the low point of
steroid production is 2 am.
And so you don't want thingshappening when the body's own
(29:11):
production of steroids is low,so we want them to dose well
before that.
I think that's what createsthat risk.
Forget is that there's actuallypublished studies that report
(29:33):
that sleep deprivation andtiredness being overtired are
both risks for reaction.
So if you've been at Six Flagsor Disney World from eight in
the morning to 6 at night andyour child can barely stay awake
(29:54):
for dinner, you're probablybetter off skipping that night's
dose.
Just skip the dose.
Yes, right.
So those are the important onesand those can apply in college,
where hours are irregular andlate nights are common and being
overtired is common.
That's why we try hard to getto a once a week dose, so the
(30:17):
child can a college student canfigure out a time that's going
to work for them, where they cando their once a week dose and
obey the safe dose rules.
Speaker 1 (30:31):
And otherwise those college kids are avoiding their
allergen.
Speaker 2 (30:35):
Yes, yes, which is okay, you know.
Food allergy is not that rarein adults either.
Right, and they adapt to it.
Mm-hmm, yes, and one student isalmost an adult.
Speaker 1 (30:57):
Touche right, right.
Um, who we've talked somewhatabout, who is and who's not
typically kind of like a goodcandidate and not great
candidate.
Um, what are some of thechallenges that parents or
kiddos kind of unexpectedly comeup against?
Like cause, cause you kind oftalked, talked about it, how in
the beginning they're kind ofthinking about one thing and
(31:17):
really just they want theirchild to not be like so allergic
anymore that they can't even.
You know, we know from anevidence-based standpoint that
even if you're very severelyallergic to a peanut, you can
still be in the room with apeanut and not have a reaction.
But they want to feel thatlevel of comfort.
(31:39):
They want to be able to seetheir child actually eating the
allergen and not have a reaction.
So I guess what are some of thechallenges that kind of pop up
along the way that you see inyour experience that maybe they
weren't expecting?
Speaker 2 (31:55):
OIT is a demanding therapy.
There is a significant burdenof care.
So in everything we do we needto balance the burden of disease
with the burden of care.
And there's a big burden offood allergy at many levels and
I don't think we have time totalk about all of those burdens
(32:16):
today, but it is important forpeople to understand there is a
burden of care During the timewhen you're doing up dosing or
starting the process.
There are office visits everyweek or every other week,
depending upon your allergist'sapproach, and so that's a pretty
(32:42):
demanding thing.
There's daily dosing andfitting that into the schedule,
which gets harder and harder asthe child gets older.
You know there are so manymiddle school kids who are
playing three sports at a time,not just three sports a year,
(33:06):
and you know they're getting upat four o'clock in the morning
for ice skating or ice hockeyand then they're playing soccer
in the afternoon and taekwondoat night.
So it's really hard to fitdosing into that kind of a
schedule Right.
So I think those are two bigelements of the burden of care.
(33:29):
And then, especially the olderchildren, some of them develop a
distaste.
I don't know what yourexperience has been.
I think it's roughly for peanut, for example.
Roughly a third can't stand it,a third are indifferent to it
(33:50):
and a third run right out andget a payday candy bar as soon
as they're able.
Speaker 1 (33:55):
Yeah, I think that's about right.
That seems about right.
Speaker 2 (33:59):
And even when the food does not give the patient a
bad taste, it's boring.
It's boring to have to eat thesame thing every time, and
that's why I try to encourageparents to mix it up a little
bit.
Food coloring, food flavors,different forms, and we go out
(34:21):
of our way to generate lists ofalternative foods that can be
substituted for people, so Ithink that helps.
Speaker 1 (34:33):
No, absolutely.
I was telling someone the otherday one of the things I love
about my practice is thatchildren come into my office and
eat snacks and that's what I do80% of my day and I love it,
right, Because they're happy,their families are happy.
And then when you check thoselabs and they're just going down
(34:56):
, it's amazing.
And when you see a child whohas had a reaction to even like
the smallest amount of peanutbutter or whatever it is, and
then you're doing your buildupand then you're beyond, you're
at the dose that caused thereaction and they do great with
it, and then they're beyond thedose.
And then you start to see thefamilies.
(35:17):
Um, we use the, so the sofa, thesurvey of food allergy anxiety,
to help kind of guide us onvery specific things.
We can set goals with ourfamilies with, like, going out
to restaurants, things like that.
So then you see families notjust saying that they feel more
comfortable, but but, butwalking that walk of being more
comfortable and yeah, they'restill like doing their due
(35:39):
diligence when they go out todinner and talking to the wait
staff and the chef and you knowall the things.
But they're doing it now andyou see them their lives opening
up, and it's it's such ablessing to be a part of that.
Speaker 2 (35:53):
Yes, yes, I would have to say that the incidents
that have impacted me most havebeen the crying moms, been the
(36:16):
crying moms, the moms who bringtheir senior in high school, who
did OIT a number of years ago,and they, through tearful eyes,
say I never would have been ableto let my child go off to
college.
Thank you, dr Wasserman.
Speaker 1 (36:28):
That gets me most.
Oh my gosh, that's beautiful,that's amazing.
That's amazing and I mean Godbless you for the work you did
(36:49):
starting back in 2008 and useyour physician mind to recognize
this process should work.
This makes sense.
There's evidence for it indifferent areas not nearly as
much as we have now and here's atrusted colleague who has had
(37:09):
experience and good experiencewith it.
And let's be mindful and let'sgive these patients the chance
to build tolerance.
That's amazing.
That's amazing.
So you know, we talked aboutsome of the difficulties with
OIT and we also talked aboutsome of the success stories.
(37:31):
I think one of the bigquestions that patients have
early on is about well, whatabout FDA approval?
So what do you talk about, orhow do you discuss FDA approval
when families ask about that?
Speaker 2 (37:50):
I have to admit that I am virtually never asked.
Really.
Yes, I may have been asked acouple of times, but I am
unenthusiastic about the medicalmedicalization of a food.
(38:10):
Yes, and this is a problem withfood and let's treat a food
problem with a food and in termsof FDA approval.
So it's something that people,many people, don't understand
(38:33):
and many doctors don'tunderstand.
The FDA does not approvetherapies or disapprove of
therapies.
The FDA approves or disapprovesindividual drugs and devices,
(38:57):
proves individual drugs anddevices, and in order to prove a
drug, the manufacturer of thedrug needs to prove that the
food is safe and effective.
Doesn't mean that's the onlyway to treat the problem and it
doesn't even mean that it's thebest way to treat the problem.
All it means is that the studythat was designed to test the
(39:20):
drug or, in this case, of food,the outcome, the predetermined
outcome, was met and the FDAgrants that approval and so that
gets the label of FDA approval.
My own feeling about theFDA-approved peanut product is
(39:43):
that there is no good datasupporting the underlying
concept, no good data supportingthe underlying concept and
that's a somewhat technicaldiscussion, but the basis of
that product.
So in order to be commerciallyviable, it had to be patentable,
(40:04):
and in order to patent it, theyhad to say they were doing
something to the peanut powderthat made it different from
off-the-shelf peanut powder.
So they measured the componentsof the different proteins in
peanut and there are more thanhalf a dozen and they made this
(40:26):
product that had a controlledamount of different proteins.
But there is no data thatthat's clinically relevant, that
it makes a difference topatients, and so I'm
unenthusiastic about that.
And in fact the way their studywas done did not reflect the
(40:52):
best information available.
And so the rate of reactions.
If you follow the packageinsert for that product with the
dose increments that arerecommended, you have a higher
reaction rate than we do whenwe're using a different regimen
based on experience.
(41:13):
So there are those kinds ofproblems.
So I have never used thatproduct and in our practice of
more than 1,200 patients, abouthalf of whom are peanut patients
, we've never used theFDA-approved product.
Plus, I can treat 400 patientsfor $16 worth of peanut butter
(41:38):
powder and I think that theFDA-approved product is a little
bit more expensive than that.
Speaker 1 (41:45):
Yes, likely.
So yes, Before we leave thatgeneral subject.
Speaker 2 (41:51):
I want to tease your audience with a new development
that I talked about before wecame on.
We talked about an annualmeeting that we have, and I've
been a consultant to a companythat has developed a peanut
(42:12):
powder with virtually no taste.
Speaker 1 (42:15):
Nice, very nice.
Speaker 2 (42:19):
If you taste the powder with nothing else, you
get a vague hint of peanut, butif you mix it with a small
amount of chocolate pudding youcan't tell that it's there.
Speaker 1 (42:35):
Oh, that's awesome.
Speaker 2 (42:36):
And that's going to be really helpful to many kids
who develop diversion to peanutand I'm hoping that that'll be
available in the US early nextyear.
Speaker 1 (42:51):
I was going to ask about when do you think it'll be
available?
That's awesome.
That's awesome.
Yeah, down here we havehurricanes, and so the concept
of a family having to rely ongetting a drug from a mail order
pharmacy or coming to my office, or when you could just go to
(43:13):
Walmart and get peanut butter,um, or now even PB two, is like
available in so many places.
It just makes so much moresense.
It just makes so much moresense, and I know that when a
peanut butter tasting lesspowder is available, that will
make a lot of mobs.
I would say especially in that8-, 9 10-year-olds and
(43:37):
definitely any of the teensdoing OIT because that has
absolutely been my experiencetoo is like the taste and the
smell.
There's just significantaversion and some of it, I do
wonder, is clearly, is clearlylike immune protection.
It's a way for their body tosay hey, don't you know, this is
not great for you.
But, also right, so like, andthere'll never be a study that
(43:59):
shows it but also there's such astrong connection with smell in
our minds and in in that agegroup and you're you're a
trained pediatrician.
Like pediatrician, you know thatthere's developmental stages
and when kids start to realizetheir own mortality and they've
been told, especially now withsocial media and especially how
much we as moms can, cansometimes put our anxiety on our
(44:22):
kids is that, oh well, this issomething that could kill me.
You know, and and we talked alittle bit before before we
started recording about foodallergy, informed therapy and
and how social media cansignificantly sensationalize
some of this and the importanceof talking with your allergist
when you have a question Um, butabsolutely that that sounds
(44:45):
like a great product and we'llhave to have you cut back when
that comes on comes out tomarket, be happy to.
I think you know I want to talkfor 25 minutes.
I think we're beyond that.
I could talk to you for hours.
God bless you for the work youdo and fastoitorg, where I mean
(45:08):
you've just done so much work tomake sure that other allergists
are able to have theinformation to help provide
these just life-alteringtherapies to families, not just
here and not just in Texas,where you are not just in the US
, but literally across the globe.
So, dr Richard Wasserman, thankyou so much.
Speaker 2 (45:29):
Thank you for the opportunity to chat with you.
It's been a delightfulexperience and your listeners
and viewers are privileged to beable to hear what you have to
say.
Speaker 3 (45:42):
Oh, thank you.
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
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, super excited to
be joined today by Dr RichardWasserman.
For those of you who have everlooked up OIT or wondered about
oral immunotherapy, chances areyou have come across Dr
(00:27):
Wasserman.
Dr Wasserman is one of thepioneers who has taken OIT and
made it what it is today, whichis significantly more accessible
to families, not just acrossthe country but literally across
the globe.
Dr Wasserman's academicaccolades are outstanding.
(00:49):
He is board certified inallergy and immunology and in
pediatrics.
His medical degree is fromMount Sinai, also UT
Southwestern.
He did pediatrics residency atChildren's Hospital of
Philadelphia, fellowshiptraining bone marrow transplant
immunology at Children'sHospital of Philadelphia,
postdoctoral cancer immunologyUniversity of Texas,
(01:11):
southwestern and immunologyrheumatology, rockefeller
University.
He has a PhD in biomedicalsciences from University of New
York, mount Sinai.
I mean um?
And then when you go to PubMedand look for Wasserman, see he's
so popular, someone's callinghim right now because of his
(01:33):
expertise and his brilliance.
That's totally fine.
Oh my gosh.
Um, I'm not surprised someone'scalling you and it's probably
somebody calling you with an OITquestion because you have
really made this amazing therapythat helps kids and adults be
significantly less allergic tofoods much more available to
(01:56):
these tens of thousands,hundreds of thousands, arguably
millions of patients.
So thank you very much forjoining us today to really talk
about oral immunotherapy.
Speaker 2 (02:09):
Thank you very much for having me.
It's a pleasure to be speakingto you this afternoon and I just
have to react to yourintroduction by saying that I've
been in medicine for a verylong time and when I grew up in
medicine, doctors were notinterested in patents and
startups.
They were interested in sharingwhat they knew for the
(02:34):
betterment of the medicalprofession and patients, and
that has been my North Star inmy practice and the activities
that I've been involved with,particularly in food allergy
treatment.
Speaker 1 (02:48):
And that really shines through, through not just
your words but literally youractions.
And that's a lot of what we'lltalk about in the interview,
(03:09):
about in the interview.
But just to sort of dive rightin, what is oral immunotherapy
For our listener who is tuningin maybe for the first or second
time and say, hey, I've heardthat name Wasserman before.
Something about OIT.
How do you introduce OIT?
Speaker 2 (03:19):
is one of the ways of retraining the body's allergy
system so that a food in thissituation, a food that causes a
problem becomes acceptable tothe child or adult with food
(03:40):
allergy, and it's one of severaltherapies that lead to what's
referred to as desensitization,which just means reducing the
sensitivity level that peoplehave to their allergenic food,
and it's really very similar toallergy shots.
(04:03):
It's, in fact, it's about as oldas allergy shots.
Allergy shots are almost 120years old and the first reports
of food therapy date back toearly in the last century, but
it's kind of lost to history fora while.
There was a report in 1935 in amajor allergy journal, but
(04:27):
nobody appeared to reallyproduce it.
And when I met Dr LyndonMansfield from El Paso, who I
had known before at a meetingalmost 20 years ago, and he told
me that he had treated a coupleof peanut-allergic patients
(04:48):
with oral immunotherapy and thatit had worked out well, I was
somewhat startled and just veryenthusiastic.
He was generous and shared hisprotocols with me, and I spent
about two years reviewing thefield and the available
literature and then we startedin the summer of 2008 with our
(05:15):
first treatment of patients withegg and milk allergy, which is
kind of interesting inretrospect, because I chose milk
and egg because I was afraid ofpeanut and it turns out that
for most people peanut's a loteasier than milk and egg.
(05:36):
So we've learned a lot in thepast 15 plus years.
Speaker 1 (05:43):
Oh, that's amazing.
That's amazing, that's amazingand that really speaks to, in
part, the culture of allergistsand the culture of what medicine
I believe needs to be, which isallergists talking to each
other and learning from eachother and sharing with each
other what works, what doesn'twork, what experience they've
had.
Absolutely, we lean intojournals and and big studies and
(06:05):
that is absolute.
Those are absolutely important.
But there's also so much wisdomin talking to others and
talking to those who have comebefore us and have experiences
that aren't necessarilydocumented or maybe it's a few
case reports here or there toreally continue to move the
(06:26):
field forward and in a way thatis you know, I keep using the
word accessible but isaccessible to families so many
times when something goesthrough a big clinical research
trial and clinical researchtrials are incredibly important
and they validate and it's justincredibly important.
Trials are incredibly importantand they validate and it's just
incredibly important, butsometimes, as you know, it can
take 10 plus years for thosefindings to really get
(06:49):
implemented into practice.
But in this day and age, whenwe can continue to have
conversations and share justlike we do with the OIT advisors
listserv sharing cases, toughcases, what worked, what hasn't
worked.
It's so helpful.
And it's helpful especially Iwill say personally and talk a
(07:09):
lot about myself on this podcast, but I would say from a
professional standpoint in mypractice I love being able to
talk, to hear your opinions onclinical cases through our email
list server.
We have hundreds of allergistsin the trenches with oral
immunotherapy, sublingualimmunotherapy, complex difficult
(07:29):
food allergy.
But because we're able to talkto each other and learn from
each other and kind of you know,you hit the nail on the head
with how you kind of spoke aboutwhat I call your spirit of
sharing information and thatthat's what medicine needs to be
about.
You know I mean God bless youBecause of all before we came on
(07:50):
.
What I told you is because ofthe work you have done.
You have allowed me and otherallergists like me to offer more
therapies to patients and it'samazing.
It's amazing and you know Ilove that you talked to him
about the history of oralimmunotherapy and that it's
amazing.
It's amazing and you know Ilove that that you talked some
about the history of oralimmunotherapy and that it's it's
it's not necessarily this supernew novel concept that it
(08:12):
really is very similar toallergy shots that we have been
doing for a very long time thatwe know work.
We know that if you slowlyintroduce an allergen to the
system, that over time it willteach the immune system in many
cases to become more tolerant toit.
So that's amazing that that'show you started it.
(08:36):
Tell me a little bit more aboutsort of the first time in your
practice.
And were you in privatepractice then?
Yes, nice.
And were you in privatepractice then, yes, nice.
And so you had a little bitmore control over how your
practice integrated new servicelines.
I would say is a nicediplomatic way to talk about
(08:59):
trying new things.
And how did the familiesrespond?
Speaker 2 (09:01):
Well, there was pent-up demand.
Well, there was pent-up demand.
(09:30):
People were looking forsolutions and you know I knew
the first and that was about1,200 patients ago.
So there's been a lot, a lothas gone on.
And your point about experienceand taking advantage of that I
think it's important for peopleto understand that doctors
shouldn't go down the gardenpath based on one experience,
but they need to be aware oftheir experience and we
(09:53):
collected our experience.
We have a spreadsheet of 120columns and now 1,200 rows of
all the patients we've evertreated and, even though they
weren't formal controlled trials, when you analyze that
(10:15):
information you can learnimportant things and one of the
differences between thoughtfulclinical practice and a research
trial In a research trial, thetrial is designed to answer
specific questions that are laidout in advance in a very rigid
way and participation in thattrial is very rigid.
(10:40):
There's not flexibility ofdosing or timing or other things
in order to get the purestanswer to the question.
But we embarked on treatmentand in treatment you learn from
your patients in what we do overthe years, by paying attention
(11:06):
to our patients and learningfrom them and using that
collected experience to thenapply that to the next round of
patients and hopefully get aneasier treatment with fewer side
effects and better outcomes.
Speaker 1 (11:24):
That's amazing.
I mean, that's what I thinkpatients hope we're always doing
is being mindful and verythoughtful and specifically
especially if it's a littlekiddo that we are thinking about
that particular childspecifically and trying to apply
(11:44):
the best possible evidence andexperience that we have to make
that child's treatment plan thebest treatment plan for that
child.
Speaker 2 (11:57):
Data is crucially important, but you and I take
care of patients one at a time,and it's the other person in the
examining room who is the focusof everything that came before
that person and applying thatknowledge.
Speaker 1 (12:17):
Oh my gosh, that's so good.
So it sounds like in thebeginning it was fairly well
received understatement.
People wanted it, of course.
Even to this day I havepatients coming in saying there
has to be more than just carryan EpiPen.
There has to be more, there hasto be more.
And I say, well, yes, there ismore.
And then we talk about things.
(12:38):
So what are some of the biggest, I would say, misconceptions
when a family first comes in andthey've heard something about
OIT, but what are some of thebiggest misconceptions that you
hear from families?
Speaker 2 (12:56):
I think the big misconceptions are that it is a
relatively short-term treatment.
So there's a lot of data aboutallergy shots that says, after
an appropriate course of allergyshots that last three to five
(13:20):
years, you can stop the shotsand the progress you've made is
enduring.
We don't have that kind of datafor OIT In fact the best
evidence because I see it atthis point says that at some
level people who are successfulin OIT need to continue eating
(13:41):
that food on a regular basis,not necessarily every day, but
indefinitely.
And so I think, even though wemake a big deal of the fact that
there needs to be indefinitedosing, when people reach
certain milestones along the wayin their treatment.
(14:07):
People reach certain milestonesalong the way in their treatment
they're inclined to think that,to say, well, now I'm cured and
I don't have to think about itand it's really.
For at least at this point,it's not correct to say that any
kind of food therapy is a cure,and food therapy can bring a
(14:28):
patient into a remission and theremission can last a very long
time without any problem.
So if someone is treated forpeanut or milk or egg or
something more exotic and istreated successfully and
maintains their treatment for aperiod of time and gradually has
(14:51):
a decreasing need for regulardosing, we still hold them on
dosing no less than once a weekindefinitely to maintain that
remission.
And I think, even though wetalk about that in the beginning
and the middle and further on,it's still kind of a surprise to
(15:11):
many families that it'sindefinite Now.
In the past several years,others and we have started
treating very young children.
In our first several hundred OITpatients we limited the lower
(15:32):
age to four years, but thenthere were reports of success
with younger children and now wewill start as young as six
months and now we will start asyoung as six months and some of
those very young children whojust had one reaction that was
(15:55):
not a bad reaction and whosetests are very weakly positive,
we may challenge them to be surethat they actually have a
reaction and then we treat themand their allergic antibody
disappears Some of them.
They go to zero, and exactlywhat's going to happen with
those children over time isunclear.
(16:18):
They may in fact have a cure.
Fortunately, there's reallygood research being done looking
at more detailed and specifictests that will tell us exactly
what's going on.
Right now we don't know for surewhether a treated patient is
(16:40):
the same as one who has outgrowntheir food allergy.
Is the same as one who hasoutgrown their food allergy?
So somebody who was allergic tomilk at age three and is now
age eight and passes the milkchallenge and is no longer
allergic, is that the sameperson allergically as somebody
who started OIT at age three andhas been drinking milk without
(17:04):
thinking about it since age fouror five at age eight?
Are they the same?
We don't know that yet, but Ithink that there are studies in
progress and very interestingtranslational research that's
looking at studies that are notused in clinic lab tests that
(17:25):
are really not availablegenerally to you and me?
That may answer that question.
I think that's one of the,perhaps one of the next
revolutions that will come downthe line.
Speaker 1 (17:39):
That will be very nice.
Yeah, I look forward to that.
What do you tell patientsregarding after they go through
buildup and they're onmaintenance and then they have
that negative ingestionchallenge so say they're eating
half a teaspoon of peanut butterfor their maintenance and then
they do a full two tablespoonchallenge and they started when
(18:00):
they were a couple of years oldI talk about.
Now you're in tolerancepreservation phase and we have
to balance out how much peanutyou need to eat to keep that
tolerance that you've built.
Kind of like you go to the gymand you've built up where you
want to be.
Well, you can't be that gazelleintense forever, right?
So you're going to kind of stepback from the gym but you still
(18:20):
want to preserve the greatprogress that you've made and
the immune system is similar,right?
So what are you seeingclinically in patients when
they're young, or maybe whenthey're in that kindergarten
third grade age, when they startOIT?
Some of the differences betweenthe early childhood and the
(18:41):
mid-childhood and even teens forwhen they start and then what
really does after maintenancelook like for them Are a lot of
them getting into, kind ofleaving it in the rearview
mirror?
I know like in my practice.
A lot of the younger kids likeit's super exciting, right?
Working with the younger kidsis awesome because we do see
(19:01):
some really promising signs thatthis is something they're not
going to have to worry about athigh school graduation.
So talk a little bit more aboutwhat sort of anticipatory
guidance you give families onwhat to expect after maintenance
.
Like, are they going to bedrinking milk every day and
going for a run, but stillmaking sure that they're doing
something at least once a week?
(19:22):
What's sort of your guidance?
But still making sure thatthey're doing something at least
once a week?
What's?
Speaker 2 (19:25):
sort of your guidance .
Well, I'm going to put theexercise issue on the side for a
minute.
Sure, To focus on the otherpart of your question.
It depends on the nature of thefood, For what I would refer to
(19:45):
as staple foods basically milk,egg and wheat, or in some
cultures it may be soybeans orchickpeas or even cashew nuts.
That are a part of some dietswhere there's going to be a
routine, frequent exposure.
A fair number of our patientsrely on their routine daily
(20:07):
consumption for theirmaintenance dosing at some point
.
Speaker 1 (20:14):
And do you still have them have?
I'm sorry to interrupt you doyou still have?
Them eat that within a safetywindow or over time?
Do you allow that guardrail tocome down?
Speaker 2 (20:24):
Well, some patients just take it down and tell me
later.
You know I hate making peoplesick and I hate reactions, and
so I, and when we started, therewas a lot more unknown and just
a great unknown.
A lot more unknown and just agreat unknown, and all of us who
(20:48):
were involved in OIT werereally nervous about the risk of
a severe reaction or gotcommitted death, and so we use
very high doses for maintenance.
What we know now is that thedoses that we use for
(21:11):
maintenance are probably higherthan they need to be, and we're
working on reducing maintenancedoses and frequency.
When we started, we demandedthat people dose seven days a
week for a minimum of threeyears, and we've modified that
(21:32):
considerably over time and we'restill learning.
These are kinds of questionsthat are answered by collective
experience.
Nobody's going to do a researchtrial comparing three years of
(21:53):
six out of seven days a weekdosing with one year of six out
of seven and two years of fourout of seven.
Nobody's ever going to do thatstudy Right.
Four out of seven Nobody's evergoing to do that study Right.
And so you just need to payattention to what patients tell
you and put together thatexperience and in a conversation
with families, explain.
(22:14):
You know, the data is clearthat the higher your daily dose
and the more you give, thebigger.
The more frequently you give it, the bigger the impact on your
allergy testing.
There's no question about that.
But how much of it is overkill,you know?
(22:37):
If you know that you can givesomebody 40 peanuts a day for
five years and theirdesensitization is likely to
last six months, is that reallymeaningful and valuable Right?
Wouldn't it be easier to havethem eat four peanuts a day?
Right, four days a week or twodays a week and go from there?
Speaker 1 (23:04):
Especially depending on their age.
Speaker 2 (23:06):
Yes, and some families would opt for the
higher, more frequent doses.
I have families who don't wantto cut back at all because
they're nervous about that.
But you know, when you start itmakes a big difference.
(23:26):
So the very young, infants andtoddlers there's much less
problem with getting them totake the dose and the food.
It's unusual to have an infantor a toddler refuse a dose or
make it hard, whereas in the 6to 12 age group it's food
(23:50):
aversion and resistance todosing is a much more common
problem.
They get bored with the dose,even if it's not that they
dislike the food.
They get bored with having todo it every day and that's very
understandable.
For teenagers it's a whole otherissue, especially because most
(24:16):
teenagers have gotten used toavoiding their food by that time
.
And there's often a mismatchbetween the parent and the child
, and the parent wants to do OITand the child at best has no
interest and often has an activeinterest in not doing it.
(24:39):
And so one of the things we hadtalked about is who's a good
candidate and who's not a goodcandidate, and I would say that
children over the age of 10 or12 have to really be committed
to wanting to do it and we havesome kids who are really
committed and want to do it.
(24:59):
But if I don't get that vibe, Iwill kind of stop the OIT
conversation and say you know,we really can't go any further
unless your child is reallymotivated to want to do this.
You're going to have enoughopportunities to fight with your
(25:21):
teenager without giving youanother one, and I definitely
don't want to make conflict inyour household for the next six
years.
And a common response to that iswell, I'm worried about what
happens when they go to college,and my answer to that is you
(25:43):
only have the illusion ofcontrol.
Now, when they start driving, orcertainly when they go to
college, the illusion will begone and, regardless of what you
say, they're going to do whatthey want to do, and so I'm
completely satisfied.
(26:04):
If a four-, five-, six-year-olddoes OIT and has a normal life
and then, at age 16, decidesthey want to stop dosing Not my
(26:26):
recommendation recommendationbut if that child has had 10
years of going to birthdayparties and eating the cupcakes
and everything at school and nothaving to sit at the peanut
table and is able to go tosleepovers and then, at age 16,
decides they don't want to doseanymore, I can live with that,
and we talk about strategies forcollege for those kids who want
(26:48):
to continue their OIT dosing.
Hopefully we get them to once aweek by then, which gives them
a lot of flexibility, becausethe safe dosing rules, which I'm
sure you tell everybody aboutwe all do are really important
and they stay important, couldyou?
Speaker 1 (27:06):
talk a little bit about that now, about safe
dosing rules.
Yeah, even when they go tocollege they're still important.
Speaker 2 (27:13):
So we know there are some things that increase the
risk of a reaction.
The most straightforward ofthem are sickness Viral
infection is the biggest butinfections in general that
stress the body.
So when a child gets sick we'llcut their dose in half for
(27:35):
several days until they getbetter and then we gradually go
back up.
Some practitioners stop dosingwhen they're sick.
We haven't found a need to dothat.
We just cut the dose in halfand that works pretty well.
The other big factor isphysical activity, and for most
children vigorous aerobicphysical activity within two
(27:59):
hours of dosing is a significantrisk for reaction.
There is the rare and Iemphasize rare child who needs a
three or four-hour window afterdosing.
That happens but it's very rare.
So you want to do that.
(28:19):
And that thing that a lot offamilies have trouble
remembering is that dosing after8 o'clock at night increases
the risk of a reaction.
So you're better off skippingthat day's dose.
If the family's been out, youcan't dose until 9 or 10 at
night.
You're better off skipping thatday.
(28:40):
That's what we recommend.
Speaker 1 (28:43):
Can you talk a little bit about why that is?
Speaker 2 (28:46):
Well, all people make steroids inside their body and
the production of steroids inthe body is circadian.
That means it follows a 24-hourclock and the low point of
steroid production is 2 am.
And so you don't want thingshappening when the body's own
(29:11):
production of steroids is low,so we want them to dose well
before that.
I think that's what createsthat risk.
Forget is that there's actuallypublished studies that report
(29:33):
that sleep deprivation andtiredness being overtired are
both risks for reaction.
So if you've been at Six Flagsor Disney World from eight in
the morning to 6 at night andyour child can barely stay awake
(29:54):
for dinner, you're probablybetter off skipping that night's
dose.
Just skip the dose.
Yes, right.
So those are the important onesand those can apply in college,
where hours are irregular andlate nights are common and being
overtired is common.
That's why we try hard to getto a once a week dose, so the
(30:17):
child can a college student canfigure out a time that's going
to work for them, where they cando their once a week dose and
obey the safe dose rules.
Speaker 1 (30:31):
And otherwise those college kids are avoiding their
allergen.
Speaker 2 (30:35):
Yes, yes, which is okay, you know.
Food allergy is not that rarein adults either.
Right, and they adapt to it.
Mm-hmm, yes, and one student isalmost an adult.
Speaker 1 (30:57):
Touche right, right.
Um, who we've talked somewhatabout, who is and who's not
typically kind of like a goodcandidate and not great
candidate.
Um, what are some of thechallenges that parents or
kiddos kind of unexpectedly comeup against?
Like cause, cause you kind oftalked, talked about it, how in
the beginning they're kind ofthinking about one thing and
(31:17):
really just they want theirchild to not be like so allergic
anymore that they can't even.
You know, we know from anevidence-based standpoint that
even if you're very severelyallergic to a peanut, you can
still be in the room with apeanut and not have a reaction.
But they want to feel thatlevel of comfort.
(31:39):
They want to be able to seetheir child actually eating the
allergen and not have a reaction.
So I guess what are some of thechallenges that kind of pop up
along the way that you see inyour experience that maybe they
weren't expecting?
Speaker 2 (31:55):
OIT is a demanding therapy.
There is a significant burdenof care.
So in everything we do we needto balance the burden of disease
with the burden of care.
And there's a big burden offood allergy at many levels and
I don't think we have time totalk about all of those burdens
(32:16):
today, but it is important forpeople to understand there is a
burden of care During the timewhen you're doing up dosing or
starting the process.
There are office visits everyweek or every other week,
depending upon your allergist'sapproach, and so that's a pretty
(32:42):
demanding thing.
There's daily dosing andfitting that into the schedule,
which gets harder and harder asthe child gets older.
You know there are so manymiddle school kids who are
playing three sports at a time,not just three sports a year,
(33:06):
and you know they're getting upat four o'clock in the morning
for ice skating or ice hockeyand then they're playing soccer
in the afternoon and taekwondoat night.
So it's really hard to fitdosing into that kind of a
schedule Right.
So I think those are two bigelements of the burden of care.
(33:29):
And then, especially the olderchildren, some of them develop a
distaste.
I don't know what yourexperience has been.
I think it's roughly for peanut, for example.
Roughly a third can't stand it,a third are indifferent to it
(33:50):
and a third run right out andget a payday candy bar as soon
as they're able.
Speaker 1 (33:55):
Yeah, I think that's about right.
That seems about right.
Speaker 2 (33:59):
And even when the food does not give the patient a
bad taste, it's boring.
It's boring to have to eat thesame thing every time, and
that's why I try to encourageparents to mix it up a little
bit.
Food coloring, food flavors,different forms, and we go out
(34:21):
of our way to generate lists ofalternative foods that can be
substituted for people, so Ithink that helps.
Speaker 1 (34:33):
No, absolutely.
I was telling someone the otherday one of the things I love
about my practice is thatchildren come into my office and
eat snacks and that's what I do80% of my day and I love it,
right, Because they're happy,their families are happy.
And then when you check thoselabs and they're just going down
(34:56):
, it's amazing.
And when you see a child whohas had a reaction to even like
the smallest amount of peanutbutter or whatever it is, and
then you're doing your buildupand then you're beyond, you're
at the dose that caused thereaction and they do great with
it, and then they're beyond thedose.
And then you start to see thefamilies.
(35:17):
Um, we use the, so the sofa, thesurvey of food allergy anxiety,
to help kind of guide us onvery specific things.
We can set goals with ourfamilies with, like, going out
to restaurants, things like that.
So then you see families notjust saying that they feel more
comfortable, but but, butwalking that walk of being more
comfortable and yeah, they'restill like doing their due
(35:39):
diligence when they go out todinner and talking to the wait
staff and the chef and you knowall the things.
But they're doing it now andyou see them their lives opening
up, and it's it's such ablessing to be a part of that.
Speaker 2 (35:53):
Yes, yes, I would have to say that the incidents
that have impacted me most havebeen the crying moms, been the
(36:16):
crying moms, the moms who bringtheir senior in high school, who
did OIT a number of years ago,and they, through tearful eyes,
say I never would have been ableto let my child go off to
college.
Thank you, dr Wasserman.
Speaker 1 (36:28):
That gets me most.
Oh my gosh, that's beautiful,that's amazing.
That's amazing and I mean Godbless you for the work you did
(36:49):
starting back in 2008 and useyour physician mind to recognize
this process should work.
This makes sense.
There's evidence for it indifferent areas not nearly as
much as we have now and here's atrusted colleague who has had
(37:09):
experience and good experiencewith it.
And let's be mindful and let'sgive these patients the chance
to build tolerance.
That's amazing.
That's amazing.
So you know, we talked aboutsome of the difficulties with
OIT and we also talked aboutsome of the success stories.
(37:31):
I think one of the bigquestions that patients have
early on is about well, whatabout FDA approval?
So what do you talk about, orhow do you discuss FDA approval
when families ask about that?
Speaker 2 (37:50):
I have to admit that I am virtually never asked.
Really.
Yes, I may have been asked acouple of times, but I am
unenthusiastic about the medicalmedicalization of a food.
(38:10):
Yes, and this is a problem withfood and let's treat a food
problem with a food and in termsof FDA approval.
So it's something that people,many people, don't understand
(38:33):
and many doctors don'tunderstand.
The FDA does not approvetherapies or disapprove of
therapies.
The FDA approves or disapprovesindividual drugs and devices,
(38:57):
proves individual drugs anddevices, and in order to prove a
drug, the manufacturer of thedrug needs to prove that the
food is safe and effective.
Doesn't mean that's the onlyway to treat the problem and it
doesn't even mean that it's thebest way to treat the problem.
All it means is that the studythat was designed to test the
(39:20):
drug or, in this case, of food,the outcome, the predetermined
outcome, was met and the FDAgrants that approval and so that
gets the label of FDA approval.
My own feeling about theFDA-approved peanut product is
(39:43):
that there is no good datasupporting the underlying
concept, no good data supportingthe underlying concept and
that's a somewhat technicaldiscussion, but the basis of
that product.
So in order to be commerciallyviable, it had to be patentable,
(40:04):
and in order to patent it, theyhad to say they were doing
something to the peanut powderthat made it different from
off-the-shelf peanut powder.
So they measured the componentsof the different proteins in
peanut and there are more thanhalf a dozen and they made this
(40:26):
product that had a controlledamount of different proteins.
But there is no data thatthat's clinically relevant, that
it makes a difference topatients, and so I'm
unenthusiastic about that.
And in fact the way their studywas done did not reflect the
(40:52):
best information available.
And so the rate of reactions.
If you follow the packageinsert for that product with the
dose increments that arerecommended, you have a higher
reaction rate than we do whenwe're using a different regimen
based on experience.
(41:13):
So there are those kinds ofproblems.
So I have never used thatproduct and in our practice of
more than 1,200 patients, abouthalf of whom are peanut patients
, we've never used theFDA-approved product.
Plus, I can treat 400 patientsfor $16 worth of peanut butter
(41:38):
powder and I think that theFDA-approved product is a little
bit more expensive than that.
Speaker 1 (41:45):
Yes, likely.
So yes, Before we leave thatgeneral subject.
Speaker 2 (41:51):
I want to tease your audience with a new development
that I talked about before wecame on.
We talked about an annualmeeting that we have, and I've
been a consultant to a companythat has developed a peanut
(42:12):
powder with virtually no taste.
Speaker 1 (42:15):
Nice, very nice.
Speaker 2 (42:19):
If you taste the powder with nothing else, you
get a vague hint of peanut, butif you mix it with a small
amount of chocolate pudding youcan't tell that it's there.
Speaker 1 (42:35):
Oh, that's awesome.
Speaker 2 (42:36):
And that's going to be really helpful to many kids
who develop diversion to peanutand I'm hoping that that'll be
available in the US early nextyear.
Speaker 1 (42:51):
I was going to ask about when do you think it'll be
available?
That's awesome.
That's awesome.
Yeah, down here we havehurricanes, and so the concept
of a family having to rely ongetting a drug from a mail order
pharmacy or coming to my office, or when you could just go to
(43:13):
Walmart and get peanut butter,um, or now even PB two, is like
available in so many places.
It just makes so much moresense.
It just makes so much moresense, and I know that when a
peanut butter tasting lesspowder is available, that will
make a lot of mobs.
I would say especially in that8-, 9 10-year-olds and
(43:37):
definitely any of the teensdoing OIT because that has
absolutely been my experiencetoo is like the taste and the
smell.
There's just significantaversion and some of it, I do
wonder, is clearly, is clearlylike immune protection.
It's a way for their body tosay hey, don't you know, this is
not great for you.
But, also right, so like, andthere'll never be a study that
(43:59):
shows it but also there's such astrong connection with smell in
our minds and in in that agegroup and you're you're a
trained pediatrician.
Like pediatrician, you know thatthere's developmental stages
and when kids start to realizetheir own mortality and they've
been told, especially now withsocial media and especially how
much we as moms can, cansometimes put our anxiety on our
(44:22):
kids is that, oh well, this issomething that could kill me.
You know, and and we talked alittle bit before before we
started recording about foodallergy, informed therapy and
and how social media cansignificantly sensationalize
some of this and the importanceof talking with your allergist
when you have a question Um, butabsolutely that that sounds
(44:45):
like a great product and we'llhave to have you cut back when
that comes on comes out tomarket, be happy to.
I think you know I want to talkfor 25 minutes.
I think we're beyond that.
I could talk to you for hours.
God bless you for the work youdo and fastoitorg, where I mean
(45:08):
you've just done so much work tomake sure that other allergists
are able to have theinformation to help provide
these just life-alteringtherapies to families, not just
here and not just in Texas,where you are not just in the US
, but literally across the globe.
So, dr Richard Wasserman, thankyou so much.
Speaker 2 (45:29):
Thank you for the opportunity to chat with you.
It's been a delightfulexperience and your listeners
and viewers are privileged to beable to hear what you have to
say.
Speaker 3 (45:42):
Oh, thank you.
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
foodallergyandyourkiddocom,where you can join our
newsletter.
God bless you and God blessyour family.
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