The use of immunotherapy for food allergies has seen recent advancements, with the US Food and Drug Administration (FDA) approval of a peanut oral immunotherapy (OIT) product and additional clinical data emerging on alternate delivery systems. These new methods and delivery options, some of which were discussed at the 2024 AAAAI Annual Meeting, may help guide individualized treatment strategies.

Following these presentations, featured expert Ruchi Gupta, MD, MPH, was interviewed by Conference Reporter Associate Editor-in-Chief Mona Shah, PharmD. Dr Gupta’s clinical perspectives on these findings are presented here.

OIT has been around for a while, and it is the first therapy that we discovered for food allergies. It makes sense: you eat the food in small amounts, you slowly increase your intake of that food, and your immune system starts recognizing it and, over time, becomes okay with smaller doses if you keep the food in your diet. In early 2020, the FDA approved peanut (Arachis hypogaea) allergen powder-dnfp, a peanut OIT. Since it went on the market right before the start of the COVID-19 pandemic, people could not go into an allergist’s office to easily get it, even though it was available. Peanut (Arachis hypogaea) allergen powder-dnfp was the only treatment with FDA approval for peanut OIT until the recent approval of the first biologic for food allergies, omalizumab.

Peanut (Arachis hypogaea) allergen powder-dnfp utilizes a protocol to methodically introduce small amounts of peanut protein into the diet. You start low, you slowly increase the amount, and then you move to long-term maintenance. You have to keep doing daily dosing at home and then go to an allergist to increase the dose. It is somewhat cumbersome on the families because it means multiple visits to an allergist. And it can be challenging to do at home because, as a person’s body is getting used to the food, sometimes they have reactions. Also, there are some restrictions in the timing of the dosing to avoid factors that can increase the person’s threshold for an allergic reaction, such as exercise. This can be challenging, depending on the family’s lifestyle and whether the child is very athletic. The pros of OIT include the fact that you are watching yourself ingest the food that you are allergic to, so you know that your body is able to manage it. The cons include the time commitment and the possibility of breakthrough reactions.

Other types of immunotherapy that are on the horizon include sublingual immunotherapy (SLIT) and epicutaneous immunotherapy (EPIT). SLIT uses doses of the allergens that are 100 times lower than those of OIT, the benefit being that the smaller doses are probably better tolerated. The negatives are that the smaller doses do not necessarily work as quickly or reach as high of a dose of allergen. With OIT, they try to take you up to multiple peanuts that your body can manage, whereas with SLIT, since the doses are so much lower, you go up a little bit slower. But again, SLIT may be easier for patients to tolerate and easier for families.

EPIT uses a skin patch that incorporates very low doses of the food protein, so the patient is not having to ingest the food. There are published data showing that EPIT increases one’s ability to tolerate small amounts of food, with most of the data being on peanut allergies.

It is important to remember that none of these therapies are curative. However, what they do allow for is more peace of mind and better quality of life, because you do not worry about accidental exposures as much. Your body can tolerate some of the cross-contact that many patients and their families are always worried about. You still cannot eat freely, and you must be careful and carry your epinephrine, but it does alleviate some of the fears of accidental exposure.

There were several interesting abstracts presented at the 2024 AAAAI Annual Meeting on this topic. One was on the use of OIT in infants (abstract 725). Because of the increasing number of young infants who are exposed early to allergenic foods, we are discovering allergies earlier. So, the questions then become: When can we start OIT, potentially even in children who are younger than 12 months of age? And, at that age, could OIT reverse the allergy and be more of a cure? That is something that a lot of people are looking at, which is very exciting.

Other abstracts presented data on the practical use of egg and milk ladders (abstracts 358, 359, 360, and 721). For both egg and milk allergies, these step-up regimens are great because they start with baked foods, which most kids love, and then they progress from there. They have really helped so many families with milk or egg allergies. They have been very successful, and you can do a lot of them at home. I love that they are getting attention.