A review of the safety of oral immunotherapy in clinical trial and real-world studies

Optimal patient selection for oral immunotherapy

Standard criteria for ideal patient selection with food oral immunotherapy (OIT) have yet to be determined. Although there are a handful of contraindications to consider before recommending OIT, most patients with confirmed immunoglobulin E-mediated food allergies are appropriate candidates. Success rates of OIT can vary widely and be influenced by several factors. Choosing the most appropriate candidate for an OIT program can mitigate risks and provide the best chance for patients to be successful.

Sublingual immunotherapy as an option for effective food allergy treatment

Food allergy sublingual immunotherapy (SLIT) has demonstrated efficacy in inducing desensitization with lower rates of systemic adverse effects than oral immunotherapy (OIT). Long-term SLIT has been shown to induce sustained unresponsiveness, and there is evidence that high-dose SLIT protocols can achieve tolerance that approximates that of OIT. However, the cost of allergenic extract may make long-term, high-dose SLIT prohibitive. Consequently, some allergists have used food allergy SLIT as a temporary bridge to OIT. Other allergists have developed SLIT protocols by using suspensions prepared from whole foods instead of commercially available extracts. Because long-term maintenance dosing regimens for food allergy SLIT have not been standardized, studies are needed to determine the minimum effective doses and duration of food allergy SLIT for various foods. Clarity on these questions may open the door to establishing food allergy SLIT as a viable treatment option.

Efficacy, effectiveness and other patient-centered outcomes of oral immunotherapy

Oral immunotherapy (OIT) is the medically supervised ingestion of a food allergen. Understanding of the expected outcomes of OIT allow for risk-benefit assessments for patient-centered decisions. The efficacy of OIT to achieve desensitization in children has been confirmed in multiple meta-analyses, even with vastly disparate study populations and methodologies. Most children initiated on OIT will achieve the ability to eat more allergen before experiencing an allergic reaction than if they continue to avoid their allergen. This effect is diminished without regular ingestion. Previous meta-analyses showed increased allergic reactions on OIT versus avoidance or placebo due to the dosing itself; however, a recent meta-analysis showed that peanut OIT in children did not lead to an increase in allergic reactions. Analysis of emerging data suggests that OIT may reduce reactions to accidental exposures over time. Important patient-centered outcomes, including reaction avoidance or amelioration, and psychosocial impacts and/or quality of life, and studies of more demographically representative populations are also necessary.