Navigating the Food Allergy Treatment Decision Process

Considering or deciding to pursue management of a food allergy is a major decision that may result in mixed emotions. Therefore, this informational handout aims to offer guidance on navigating the exploration process and psychological considerations associated with food allergy treatments.

Food Allergy Treatments Available

The cornerstone of management remains strict allergen avoidance and treatment of accidental ingestions with epinephrine. However, people are choosing to explore food allergy treatments in order to build tolerance that may protect against a reaction in case of accidental allergen exposure. These treatments are not cures, but aim to offer desensitization through carefully controlled ongoing allergen exposure. Additionally, there are risks and benefits with all treatments.

The following are food allergy treatments currently being offered or researched via clinical trials. (Refer to the American College of Allergy, Asthma and Immunology for more information)

• Oral Immunotherapy (OIT) - Ingestion of increasing amounts of allergen orally.
• OIT protocols using regular foodstuffs have been used for over a decade in private practice
  • Multiple published approaches in both academic and private practice settings
• In 2020, FDA approved Palforzia: a 12% light roast, defatted peanut flour OIT product (4-17 years)
  • Flour in a capsule, capsule not ingested.
  • Uses FDA-approved good manufacturing practices (standardized doses).
• Epicutaneous Immunotherapy (EPIT) - application (not ingestion) of allergen via patch placed on the skin.
• Biologics including omalizumab and dupilumab are currently being investigated for their therapeutic use in food allergies. Results to date are promising, suggesting efficacy and tolerability.

Other Recent Publications

• The Immune Tolerance Network IMPACT trial funded by the NIH involving ~150 children found that giving peanut OIT to highly peanut-allergic children ages 1-3 years safely desensitized most of them to peanut and induced remission of peanut allergy in 21% of participants. Maintenance was 6 peanuts (2g) for ~2.5 years. Remission defined as being able to eat 16 peanuts (5g) of peanut protein, without having an allergic reaction 6 months after completing immunotherapy. Lower levels of peanut-specific IgE at the start of the trial and being younger predicted whether a child would achieve remission. Nearly all participants had at least one dose-related reaction during treatment, most were mild to moderate in severity. 21 children received epinephrine for 35 moderate reactions.

Interpretation: Initiation of OIT before age 4 was associated with an increase in both desensitization and remission. Development of remission correlated with immunological biomarkers. There is window of opportunity at a young age for intervention to induce remission of peanut allergy.

Jones SM, et al; Immune Tolerance Network. Efficacy and safety of oral immunotherapy in children aged 1-3 years with peanut allergy (the Immune Tolerance Network IMPACT trial): a randomized placebo-controlled study. Lancet. 2022 Jan 22;399(10322):359-371.

• The Peanut Allergy Burden Study (PABS) is a cross-sectional quantitative survey designed to determine the real-world experience of patients and caregivers with PA. The objective of the study was to  understand the real-world utilization of PArelated healthcare resources and the impact of PA on productivity.

Conclusion: many healthcare resources were utilized by patients with PA and there was a loss of productivity associated with PA for patients and caregivers.

McCann W, World Allergy Organ J. 2021 Mar 26;14(3):100525.

• Open-label follow-up of Palforzia: the benefit of daily administration of Palforzia has been established in clinical trials, but limited data past the first year of treatment are available. This longitudinal analysis aimed to explore the impact of continued Palforzia maintenance dosing (300 mg/day) on efficacy, safety/tolerability, and food allergy-related quality of life.

Conclusion: daily treatment with Palforzia beyond 1 year leads to an improved safety/tolerability profile and continued clinical and immunological response.

Fernandez-Rivas M, Allergy. 2021 Jul 28.

Consider the Following When Exploring Food Allergy Treatments

• Explore Motivations: Explore your and your child’s motivations for undergoing treatment. While the reasons may differ, it’s important to continually assess everyone’s motivation throughout treatment, as they may change and impact commitment levels.

• Determine Commitment: Assess your and your child’s level of commitment, as this may help determine if treatment is a good fit, and even when to begin treatment. All food allergy therapies require significant commitment.

• Assess Anxiety or Fear: Assess anxiety prior to starting treatment. While experiencing anxiety and worry is normal before and during treatment, excessive anxiety prior to the onset may be a factor in deciding when to begin a treatment.

• Evaluate Confidence in Provider: Ask questions that will help determine your level of comfort and confidence in the board-certified allergist administering the treatment.

Evaluation Process Before Beginning Treatment

Before enrolling in a food allergy treatment, it’s important to gather enough information to help not only make the decision whether or not to pursue it, but also to evaluate the board-certified allergist providing the treatment. Below is a question guide to help navigate this evaluation process.

Treatment & Provider Information: 
• What are the goals, expected outcomes, and specific protocols for treatment? 
• Are oral food challenges required to confirm the allergy before starting treatment? 
• Are oral food challenges required to determine effectiveness of the trearment? 
• What is the follow-up or maintenance protocol after treatment? 
• What is required of you/your child (i.e. appointment frequency, daily protocols)? 
• Will treatment impact school, work, activities, or daily routines, and if so, how? 
• How are viruses or illnesses navigated while taking part in the treatment? 
• How does the provider address treatment-related anxiety that may arise? 
• How familiar is the provider with the treatment?

Potential Benefits & Risks of Treatment: 
• What are the potential risks and benefits of the treatment, medical or otherwise? 
• Are anaphylactic reactions a potential risk of treatment? 
• What are potential treatment setbacks, their likelihood, and how they are handled?

Office Procedures: 
• Will appointments be with the provider, or associates within the practice? 
• Is a provider on call 24 hours/day in case of emergencies?

Develop A Flexible Food Allergy Treatment Mindset

Experiencing rigid thoughts and actions is natural when faced with uncertainty, discomfort, and distress. However, flexibility, or the ability to adapt, is beneficial when navigating treatments.

The following tips can help establish a flexible mindset and approach to food allergy treatments: 
• Establish open communication with your board-certified allergist and treatment team. 
• Engage in shared decision-making to develop treatment timeline and goals. 
• Understand that treatment is a process rather than just a desired outcome. 
• Prepare for the possibility of setbacks, the need to alter approaches, or stop treatment 
• Monitor anxiety levels, reaching out for counseling or support services if excessive.

Download FAACT's Navigating the Food Allergy Treatment Decision Process poster here.