If you have heard of OIT or SLIT (oral immunotherapy and sublingual immunotherapy, respectively), then you've probably wondered how these therapies treat food allergies and, if they are so great, why isn't everyone doing them? Well, in part, it's due to potential risks, but there are also some other factors to consider.
Join Dr. Hoyt as she discusses all this with her colleague Dr. Sakina Bajowala. Dr. Bajowala is a board-certified allergist with specific expertise in the treatment of food allergies. She practices outside of Chicago and helps families navigate the world of food allergy and, in many cases, helps make her patients significantly less allergic to foods. Dr. Bajowala is a Fellow of the American Academy of Allergy, Asthma and Immunology and is incredibly well respected by her colleagues in the OIT space.
Note: the doctors mention a couple resources during this episode:
https://www.foodallergycounselor.com/
https://solidstarts.com/
What's your food allergy question? Subscribe to our newsletter to ask your questions!
Looking for one-on-one time with a food allergist to finally get your food allergy questions answered? Sign up for Food Allergy Office Hours for Parents!
Engage with us on Instagram!
Are you in need of an allergist in your area?
AAAAI Allergist Finder
ACAAI Allergist Finder
OIT Allergist Finder
Would like to become a patient? Reach out to the Institute!
Does your kiddo's school need help with medical emergency response planning? Check out the non-profit Code Ana.
This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.
If you have heard of OIT or SLIT (oral immunotherapy and sublingual immunotherapy, respectively), then you've probably wondered how these therapies treat food allergies and, if they are so great, why isn't everyone doing them? Well, in part, it's due to potential risks, but there are also some other factors to consider.
Join Dr. Hoyt as she discusses all this with her colleague Dr. Sakina Bajowala. Dr. Bajowala is a board-certified allergist with specific expertise in the treatment of food allergies. She practices outside of Chicago and helps families navigate the world of food allergy and, in many cases, helps make her patients significantly less allergic to foods. Dr. Bajowala is a Fellow of the American Academy of Allergy, Asthma and Immunology and is incredibly well respected by her colleagues in the OIT space.
Note: the doctors mention a couple resources during this episode:
https://www.foodallergycounselor.com/
https://solidstarts.com/
What's your food allergy question? Subscribe to our newsletter to ask your questions!
Looking for one-on-one time with a food allergist to finally get your food allergy questions answered? Sign up for Food Allergy Office Hours for Parents!
Engage with us on Instagram!
Are you in need of an allergist in your area?
AAAAI Allergist Finder
ACAAI Allergist Finder
OIT Allergist Finder
Would like to become a patient? Reach out to the Institute!
Does your kiddo's school need help with medical emergency response planning? Check out the non-profit Code Ana.
This podcast is the official podcast of the Hoyt Institute of Food Allergy. Information on, within, and associated with this site and Food Allergy and Your Kiddo is for educational purposes only and is not medical advice.
Welcome to.
Speaker 1:Food Allergy and your Kiddo with Dr Alice Hoyt the podcast about demystifying food allergies, diminishing allergy anxiety and taking back control. Let's navigate this challenge together with evidence-based information, scientific research and tried-improven practices. And now here's your host board-certified allergist and immunologist specializing in food allergy, Dr Alice Hoyt.
Speaker 3:Hello and welcome to the Food Allergy and your Kiddo podcast. I am your host, dr Alice Hoyt, over the moon excited about today's guest. Dr Sakina Bajawala is a board-certified allergist and pediatrician and she practices in the western suburbs of Chicago. And Dr Bajawala you might know her from her writings on Web Nd. Also, she is one of those amazing docs involved in solid starts that is all over Instagram helping new mamas and papas be able to give their kiddos age-appropriate food, but not just mushy, mushy, mushy food. So I'm so excited to have you today, sakina. Welcome to the podcast.
Speaker 2:Well, thank you, Alice, for having me. I'm delighted to be here.
Speaker 3:Today, what I really want us to talk about is really optimizing safety during immunotherapy, specifically oral immunotherapy, sublingual immunotherapy, the food immunotherapies or desensitization. And so, if you're new to the podcast and listening, we've had lots of episodes one, what is oral immunotherapy? I'll talk about what is sublingual immunotherapy, but today I really want us to focus on the safety of it all. And so, dr Bajawala, when a family first comes to see you and you'll have the discussion about desensitizing their kiddo to a food, what are some of those first safety questions you feel you're feeling the most?
Speaker 2:I would say the number one fear and concern that families have when we broach the subject of food allergen desensitization is the risk of anaphylaxis. After all, for most families, the reason that they're even considering food allergen desensitization in the first place is they would like to avoid anaphylaxis in the future. So many of them have encountered literature or online articles claiming that the risk of anaphylaxis from a food allergen is actually increased during food allergen desensitization compared to strict avoidance, and that, of course, is concerning to them, and so they're always asking if the whole point of this is to avoid anaphylaxis and there's an increased risk of anaphylaxis during food allergen desensitization, what are we doing here at all, and what are you going to do to minimize my child's chances of experiencing such a reaction, and what can I do as a parent to do the same?
Speaker 3:And how do you answer that very specific, yet very common, super common question?
Speaker 2:Yeah, I would say. Well, the first thing I do is explain the difference between overall incidence of anaphylaxis during a course of immunotherapy and compare that to the risk of anaphylaxis as a function of the number of exposures, right? So when you're comparing how often someone might experience an allergic reaction and use that as the numerator of a fraction and then divide that by the number of exposures during that time period as a denominator, that ratio is more reflective of how effective immunotherapy is. So in the event of strict avoidance, that ratio is higher than what you would see during the course of food allergen desensitization. And the reason as a function of number of exposures, the rate of anaphylaxis is relatively low during oral immunotherapy is because, as allergists, we are working very hard to optimize baseline health prior to the initiation of treatment.
Speaker 2:So we think about this concept of a bucket that holds your allergic inflammation. And there is only so much inflammation that this bucket can hold before it overflows and says I give up, I'm going to have a reaction, right. And so many different things contribute to this bucket. If you have uncontrolled eczema, that fills the bucket up a little bit. If you have poorly controlled asthma, it fills the bucket a little bit more.
Speaker 2:If your environmental allergies are very, very active. The bucket is further still. And then, on top of that, if you introduce daily exposure to a food allergen, you have very little space left in that bucket before it overflows. Now, if you focus instead on not being so intent on starting food allergen desensitization as soon as possible, but rather take your time and empty that bucket out Right, so get asthma under control, get eczema under control, get your environmental allergies under control. If there's any constipation issues, get that under control, all of a sudden the level of the bucket is down here and now you have more wiggle room to put a food allergen in on a regular basis with a total overflowing. So that is job number one Optimizing baseline health, and it's enormously important to the safety of immunotherapy long term.
Speaker 3:Love that, love that, especially, I would say, with our asthmatic kiddos and really making sure that, even if they have what you think is maybe mild intermittent asthma, but then really doing a good deep dive into how much asthma is that kiddo having, how many times is that kiddo wheezing or coughing with a viral infection or with allergen exposure, and really optimizing that asthma regimen, even sometimes starting an inhaled corticosteroid sooner than maybe you would if they weren't starting OIT. Maybe you try singular, maybe you try optimizing something else or a little bit heavier on the, on the antihistamine or nasal spray or whatever you want to do to minimize the allergen, the allergy load, I guess I would say. But I find that I am now much quicker to try to optimize, especially asthma, definitely eczema, definitely seasonal allergies, but especially asthma. I agree.
Speaker 3:I especially sense with asthma.
Speaker 3:We do not want an asthma, we don't want an asthma reaction.
Speaker 3:We don't ever want, I don't ever want, I don't think you ever want the lungs involved in these anaphylactic reactions or these even mild reactions that then could potentially be worse than when you're doing every day at risk of having an allergic reaction.
Speaker 3:The other thing that I like to think about with OIT and optimizing safety is really and sort of the numerator-genomic discussion that you were talking about is thinking about when somebody is having an ingestion of their allergen.
Speaker 3:If they're on an avoidance pathway meaning that they're not on OIT or slit and they have an accidental ingestion and they have a reaction. That's gonna be a completely different anaphylactic situation than when you're doing oral immunotherapy and you know that you're giving your child a very particular amount of a very specific allergen and you have that safety window, especially with OIT, with slit, we can talk a little bit about the safety with slit, since it has such a better safety profile regarding the daily dosing and the safety window, as I call it. But really just a reaction that you have with OIT is gonna be just so much. It's a much more controlled environment than heaven forbid those calls that we get from moms when their kiddo has an accidental ingestion of something at school and they don't know how much of it it was, or if it's a kid with multiple food allergies, they don't know which allergen it was. And those reactions, with so many unknowns, I feel like they just weigh so much more on families than the potential of the OIT reactions Is that sort of in your experience.
Speaker 2:Absolutely right. The difference between anaphylaxis out in the field versus during oral immunotherapy is that in oral immunotherapy you have a precise dose under optimized conditions, under supervision and so you need to Right and I'm gonna stop you right there to make sure our listeners understand optimized conditions.
Speaker 3:Whenever we're doing oral immunotherapy especially for new to the podcast whenever we're doing oral immunotherapy with a family, we give them parameters by which to either contact us or absolutely do not dose, such as if you're having a fever, if your kiddo is having a fever, who's doing the OIT right, vomiting out in the heat, which I know right now across the country. It's just been madness. So anything that's raising the body temperature, increasing the heart rate, those are gonna lower the threshold to have an allergic reaction. And so, sakina, I mean you're hitting the nail on the head. It's we are under optimal conditions when we're doing OIT.
Speaker 3:And one little tangent sometimes if you're not a new listener then you know that sometimes tangents occur on this podcast. Many times when we have reactions with OIT it is because there has been an oops. You're right, he had a fever earlier and I gave Tylenol. Then I totally forgot, or he hit his arm and so I gave him a motrin and I totally forgot that motrin can lower the threshold and that I'm supposed to call you about that or hold the dose. So definitely those confounders that happen. But yeah, I think we see the same thing about the. When a reaction is happening during OIT, it's just such a different, it's just a different situation than when it's happening in the field.
Speaker 2:Yeah, and it can be really easy for families to get a little bit complacent after things have been going very well for a long time. So of course we give the printed out list of safety rules and of course we have 24-7 availability to answer questions related to oral immunotherapy dosing, because I would much rather that a family reach out to me at 6.30 in the morning and ask me a question so I can say you know what you need to skip your dose today, rather than worry that they're going to bother me and then just say, oh, it probably is fine, I don't want to call her, give the dose. And then they got to call me anyway because the kids needing any Right, right. So I always say I will never be upset, my step will never be upset if you call me with a question, and so we get a lot of questions, right. And so one of the things we started doing is we realized that our safety rules apply to all of our patients.
Speaker 2:Right, we have a protocol, my colleagues have protocols, you have internal protocols and for the most part our safety rules as an oral immunotherapy community are pretty uniform. They may not be exactly the same, but conceptually they're the same. We want to make sure that the dose is administered not on an empty stomach, without a fever, without active illness, without active asthma symptoms. We want to control the heart rate and the core body temperature around dosing time. We want to make sure that those factors that might increase the risk of having a reaction are controlled for so I don't want kids dosing late at night. I don't want kids dosing when their routine has been completely disrupted, or if they had a horrible night of sleep and they're exhausted, or if they've been out all day.
Speaker 3:Cut out a little bit, but I think what you said is that you don't want them dosing when their routine has been interrupted and they're exhausted and sleep deprivation.
Speaker 2:Yeah, we actually have data in peanut allergy showing that sleep deprivation and dehydration are associated with an increased risk of peanut anaphylaxis and we can extrapolate from the data about peanut to making safety rules for the deliberate exposure of peanut and other food allergens in these patients. So, knowing that all of us have these very similar and somewhat standardized safety rules, we've tried to integrate that into our protocol. So we have all of our patients like log their doses regularly and there are screening questions that pop up. Before they log their doses they say in the last 24 hours, have any of these things occurred? If they have, they click a box and it tells them you need to reduce your dose or you need to skip your dose today.
Speaker 3:You have an app for that right. What is the name? Of your app.
Speaker 2:The app is called the Food Allergy Fix Mobile App.
Speaker 3:Nice, nice. We'll put a link to that in the show notes. That's awesome.
Speaker 2:And you know these rules are things that most allergists are doing anyway, right? They're giving it to their patients. So pretty much all patients are being asked to follow very similar rules and, like I was saying earlier, it can be easy to fall out of the habit once things have been going well for a while. So what you mentioned earlier, Alice, those oops moments Pretty much any time there's anaphylaxis, when we debrief and look backwards, we find that oops moment right, and I think that's probably your experience as well.
Speaker 3:Yes, it is, and it's reassuring, right? It's reassuring that for the most part, kiddos do very well with oral immunotherapy. For the most part that there's not necessarily a lot of big surprises along the way if we're following a good protocol for that patient.
Speaker 3:I know that I am. I would say I'm very proactive allergist, but I'm also very conservative, and what I love about being in my practice is that I'm not confined by any sort of research protocol. Right, because the horse is out of the barn like, oh I teamwork, right, we don't need a research protocol for it. It was nice about it in particular is that if a mom says you know what, she just really hasn't been feeling. Well, do you think we should up dose Like she doesn't have a fever or anything? But I'm like, nope, let's wait till next week.
Speaker 2:That's always air on the side of caution, and I think most allergists will do that, because it is not a race, it's a marathon.
Speaker 3:Slow and steady and it's not a race.
Speaker 2:It's not a race, it doesn't matter how fast you get to the finish line, it just matters that you're still in the running. And I am just like you. If I get that call I'll say, yeah, skip, it's fine, we'll get back on track tomorrow. And people are so stressed I'm like, oh, but if I miss a day I'm going to throw everything off. And no, you're not.
Speaker 2:I have some patients who missed, for I mean, during the peak of the COVID pandemic, when people were getting COVID right and left, I had patients who were symptomatic with their illness and they were missing their dose for seven, 10 days at a time. And they didn't have to start all over, we just took them back a little bit, brought them into clinic, made sure they could tolerate a slightly reduced dose and built them back up. And I think having a sense of reassurance and calm and trusting the process is very important because you know we've talked about the organic and physical aspects of health optimization in safety optimization prior to oral immunotherapy. But there's a really, really important behavioral, emotional, psychological component to the safety of oral immunotherapy that cannot be ignored. And this is not only in the patient but also in, perhaps more importantly, in the caregivers.
Speaker 3:Yes, absolutely, absolutely, and I think that's a good point to make. Before we started the recording, we were talking about one of our mutual colleagues. One of our mutual friends, tamara Hubbard, and food allergy counselor, and I just think that the work that Tamara does is so important and having food allergy informed counselors is very important. We have one here at the White Institute of Food Allergy and so if you're listening to this and you're like, wait, there's a food allergy informed counselor yes, a little link to that and the show notes too.
Speaker 2:There's a whole directory.
Speaker 3:Yes, it's amazing and you're exactly right, like having that improvement in the quality of life that comes with doing oral immunotherapy. But recognizing that starting in oral immunotherapy depending on the kiddos age of course can be very stressful for the kiddo but or anxiety-provoking I should say. But then for the parents making that decision it can be just such a hard decision to make, especially given the potential impact on activities, because oral immunotherapy does have that that about hour before, two hours after not doing anything that's raising the heart rate or the body temp. Which I want to get into this discussion, just at least a little bit about sublingual immunotherapy, because sublingual immunotherapy has a much different safety window. So talk to our listeners a little bit about sublingual immunotherapy and how its safety window is different in your practice from that in oral immunotherapy.
Speaker 2:Sure, so, as we know, oral immunotherapy is a way of retraining the immune system to tolerate an allergen that it is currently overreacting to, and in oral immunotherapy we are administering the food allergen via the mouth to be swallowed and digested and absorbed and exposed to the immune system through the immune tissues in the gut, particularly the small intestine. In sublingual immunotherapy we are using much lower doses of allergen and instead of directly swallowing a food, we are delivering these tiny doses of allergen to the immune cells that reside in the mucosa under your tongue, right there. So there are cells white blood cells, called dendritic cells that reside in this space that have the capacity to capture allergen, take it back to the local lymph nodes and break it down into tiny little pieces in the process, and in those lymph nodes these white blood cells will present those pieces of the allergenic proteins to other white blood cells and start this cascade of immunologic crosstalk that eventually sends a signal to the white blood cells in the bone marrow to trigger class switching and move away from an allergenic profile and more towards tolerance. And this happens on a very, very tiny level and it's the cumulative exposure over time that builds up that tolerance. And as you build up tolerance to the tiniest amount, then we increase the dose and increase the dose and so on and so forth. But because sublingual immunotherapy is to a large extent bypassing the lower part of the gut and it's using such small doses, the risk of reactivity is significantly lower compared to oral immunotherapy, which then also means we can ease up on some of our safety rules.
Speaker 2:I still insist on baseline health optimization prior to the initiation of sublingual immunotherapy, just like I would with oral immunotherapy. So I'm not going to start sublingual immunotherapy in somebody with horrible asthma, for example, unless I can get it well controlled. But once we begin, once health is optimized and then we begin sublingual immunotherapy, the safety rules are more relaxed. It doesn't mean they're non-existent, but they're not astringent. So, for example, you don't necessarily need to have food in your valley before you take sublingual immunotherapy.
Speaker 2:You do not need to have as long of an exercise restriction and some people might argue that there is no exercise restriction required at all for sublingual immunotherapy. In my practice we still do one hour after. That's speaking to our conservatism. But overall the risk of a systemic reaction or anaphylactic reaction is much lower in sublingual immunotherapy than it is in oral immunotherapy, even though the dose, precisely because the doses are so much lower. And so of course then there's this concern will sublingual immunotherapy give me the same levels of protection as oral immunotherapy? And that can be a whole other conversation, probably, but the evidence is emerging that if continued for long enough at high doses for sublingual immunotherapy, low compared to oral immunotherapy, you can still get really significant levels of protection with long term sublingual immunotherapy. So it might be a very viable treatment alternative for patients who aren't good candidates for oral immunotherapy or find the exercise restrictions associated with oral immunotherapy to be too cumbersome to follow long term.
Speaker 3:I'll be excited. Maybe we can repeat this conversation in five years. Oh yeah, just how much has changed in five years? Because right now I practice pretty much the same way as you, which is fun to find out, because before this conversation we hadn't talked very much at all. So it'll be cool to see where all this goes in the next five years, because if we'd had this discussion five years ago, it would be a completely different discussion, and so it's it's a very exciting time I find to serve food allergy families.
Speaker 2:I think it's a great time to serve food allergy Absolutely. I tell my patients all the time. If I had to be diagnosed with a food allergy in any decade, now is the time. Right Now is the time because we actually have things that we can do to change the natural history of the disease, and the pace of advancement and innovation in the food allergy space is astounding. Right now it seems like every every month I turn around and there's some brand new development. And you know, the nice thing is there are multiple ways that you can go about desensitization. So of course, we have oral immunotherapy, sublingual immunotherapy, there will soon be epi-cutaneous immunotherapy down the road, intralemphatic immunotherapy, perhaps oral mucosal immunotherapy so many different ways to introduce the allergen into the body. And the key is having expertise in all of these modalities and not just one, so that when a patient comes to you you can put the right patient on the right treatment for them.
Speaker 3:I couldn't have said it any better. Thank you so much for coming on the podcast and talking about this today. I can tell already this is going to be a very downloaded episode.
Speaker 2:It's my pleasure. Thank you so much for having me.
Speaker 3:That's the episode. Thanks so much for tuning in. Of course I'm an allergist, but I'm not your allergist. So talk with your allergist about what you learned on this episode and visit us at foodallergyandyourkiddocom, where you can submit your family's questions. God bless you and God bless your family.