Options for the diagnosis and treatment of food allergies are advancing quickly, and it is becoming even more important to involve patients and their caregivers in the decision-making process. Clinicians often have their own preferences based on published evidence, guidelines, and clinical experience, but the best treatment pathway for an individual patient requires their informed decision based on factors that include the logistics, benefits, risks, side effects, duration, and costs of the various treatment options, as well as considerations such as personal preferences.

A food allergy is a unique chronic condition because a patient does not have physical symptoms every day, so sometimes they may perceive more of a burden from the treatment than from the condition. Shared decision making is particularly important in food allergies because many of the decisions regarding diagnosis and management are preference based. Additionally, diagnostic and treatment options in food allergies are expanding rapidly, so it is critical to involve patients and their caregivers in decision making.

Before embarking on a food allergy immunotherapy journey, it is critical to determine the patient’s goals. Some patients may choose food avoidance, while others actively seek more proactive management with allergen-specific immunotherapy or omalizumab; these decisions are based on their assessments of the risks and benefits. We have to provide the information they need to make an informed decision about treatment, including logistics, duration, cost of therapy, anticipated outcomes, and potential side effects. All these considerations need to be discussed, and patients’ and caregivers’ questions have to be addressed, which can be time consuming. A decision support tool is available to guide decisions about whether to start oral immunotherapy vs continuing food avoidance, although additional tools should be developed as new management options become available.

Patient preferences may change over time, particularly for children, who, for example, may not be interested in food immunotherapy when they are 10 years of age but may become very interested before leaving for college at 17 or 18 years of age. Older teenagers are more willing to explore treatments that are not administered daily and do not impose lifestyle modifications but can provide some level of protection from accidental exposures, such as omalizumab. There are also many other treatments in the pipeline that will become available in the future and might be more suited to an individual patient. Therefore, it is important to have periodic reevaluations and discussions about the new therapies to help patients make informed decisions.

With respect to the age at which patients can participate in shared decision making, for many chronic diseases, older children may begin to assert preferences regarding treatment decisions. This age is likely younger for oral immunotherapy because children between 5 and 7 years of age already have strong taste preferences, understand that eating their food allergen(s) is dangerous, and may be reluctant to participate in daily treatment. As they get older and begin to experience the practical consequences of food avoidance and associated lifestyle restrictions, they may be more willing to explore other options, such as a biologic given infrequently, which not only provides a layer of protection but also offers the potential benefit of controlling other allergic comorbidities.