Newer therapies for food allergies include oral immunotherapy (OIT) and biologics. Treatment selection should consider both clinical- and patient-/caregiver-related factors, including food insecurity and patient/caregiver anxiety. These factors were discussed at the recent American College of Allergy, Asthma & Immunology (ACAAI) 2024 Annual Scientific Meeting.

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

When a child is diagnosed with a food allergy for the first time, and their family is trying to navigate the process, first we go through the US Food and Drug Administration (FDA)–approved treatment options, which, for the longest time, was just avoidance. A lot of patients come to us because they do not want to go down the avoidance route. We now have 2 additional FDA-approved options: peanut OIT (ie, peanut [Arachis hypogaea] allergen powder-dnfp) and omalizumab.

OIT is often offered off-label for a variety of food allergens by clinics that are equipped and set up to do so. It is important to note that OIT does have a significant impact on lifestyle for a child and their family due to the everyday dosing. Further, approximately 45% of our population actually has multifood allergies (ie, up to 3 or 4 food allergies and not just 1). That is when OIT gets even more complicated and time-consuming, because you are not just dosing 1 food every day, you are dosing 3 or 4 foods, and that can become very tiresome.

In addition, food insecurity can play a role when considering OIT. As highlighted in the study by Gabriel Mendoza, MD, and colleagues presented at the ACAAI 2024 Annual Scientific Meeting, strategies such as the early introduction of potential food allergens and OIT can be harder to pull off in a family with food insecurity, and early intervention and better management strategies are all-the-more important in this population (abstract R315).

Anxiety can also play a big role in deciding which treatment option to choose. We are managing anxiety in some children because they are afraid of needles or of the food that the daily OIT requires them to eat. We have also seen a lot of caregiver anxiety, as discussed at the ACAAI meeting by Kaitlyn Wang et al, who showed in their study how this is not just a disease impacting one individual—the patient’s family is also impacted (abstract R306). The data showing that food allergy–specific anxiety among caregivers changes over time are interesting. This information can help provide more tailored guidance for our families. Caregiver anxiety is more profound when patients are young, but, as the child gets older, parent anxiety decreases. However, as caregiver anxiety might begin to decrease as the patient ages, I think that patient anxiety may actually increase with age. For example, newborn to 5-year-old children being treated with OIT are usually not worried about ingesting the food, whereas 6 to 12 year olds often get very anxious and worried. In fact, you can see the panic in some of their faces as they are coming in for either OIT or their omalizumab injection. OIT is hardest for the adolescent age group, not only because of anxiety but also because these patients are trying to be more independent and take more ownership of their health, and with it—more risks. And that often results in them not taking the OIT dose every day. So, if patients in this age group are struggling with OIT, an omalizumab injection may be a better option.

We see a lot of dosing fatigue with OIT among patients and their families as well. If a child with food allergies is also a picky eater, it is already a battle trying to get them to eat food. OIT also requires lifestyle changes or considerations. It may be difficult to think about how OIT can be inserted into their lifestyle without too much disruption. It can get very tricky, especially for a child who is playing multiple sports, is in and out of the house, and/or is in a split household. For such children, I do bring up the option of omalizumab, and we discuss whether it is better for them than OIT at that time. With omalizumab, it is fantastic that you get an injection without any real limitations to daily lifestyle. That being said, it is really scary to administer injections to your child, and we do see a lot of needle-phobic children. In addition, some people may be worried about the long-term consequences of injecting a biologic on a patient’s immune system.

Shared decision making is important because there is no single correct answer. Avoidance, OIT, and omalizumab are all options, and there are many other options in the pipeline, so the discussion will become even more important. It is really about going through the pros and cons of each treatment option and providing reassurance that even if something is the right option now, it is okay down the line to explore something different.