Xolair or OIT? The better option is...

The headlines makes it sound simple: omalizumab (Xolair) performs as well as or better than multi-food oral immunotherapy for food allergy. But once you look under the hood, the story gets a lot more nuanced and a lot more real. Fresh from the AAAAI 2026 conference, I walk you through what the new data actually show, why the study design isn't ideal, and what parents should ask their allergist before choosing a path, whether that be with Xolair, OIT, SLIT, or avoidance.

Link to the articles I mention:

Food Allergy Peds Hub: https://foodallergypedshub.hoytallergy.com/newsletters/the-food-allergy-friday-newsletter/posts/is-xolair-superior-to-oit

Doximity: https://opmed.doximity.com/articles/aaaai-2026-good-science-great-connections

If this helps you think more clearly about your child's food allergy treatment, subscribe, share the episode with a friend, and leave a review so more families can find it.

Resources

📖 Navigating Food Allergies: A Parent’s Guide to Care, Coverage, and Confidence by Dr. Alice Hoyt - preorder from Amazon and more 

For Parents ➡️ Office Hours for Parents 

For Providers ➡️ Food Allergy Pediatric Hub

For Schools ➡️ Code Ana

For Potential Patients ➡️ Hoyt Institute of Food Allergy

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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.

Transcript

Conference Takeaways And Why They Matter

SPEAKER_01 0:06

Hello and welcome to Food Allergy and Your Kiddo. I'm your host, Dr. Alice Hoyt, fresh back from the American Academy of Allergy, Asthma and Immunology conference in Philadelphia. And it was really a very, very, very good conference. I wrote a piece on the comp uh about the conference on Docsimity, which is this doctor social media medical focused platform. So any of my doctor listeners, hi, check out your Doximity for an article. And I'll post a link to it in the show notes because really what I went into in the article was the value of colleagues and growing relationships with colleagues and how one of my mentors many moons ago gave me some very, very good advice about every time you go to a conference, meet somebody new. And I'm really seeing the fruits of that really start to bloom. And it was really lovely to see so many of my colleagues, my friends in Philadelphia and talk shop, talk life. It was awesome. What was also awesome is that we, you know, when we go to these conferences, we as allergists, then we're hearing some of the coolest um updates when it comes to food allergy. And what I want to talk about today is a concept that I talked about last year about omalismab being superior to oral immunotherapy for food allergy. They being the academy for like what, you know, what really like awesome new data is being presented at the conference. Like, that's great, like, right? Cutting-edge science. That's what we want. Um more data from the Outmatch study was released. And the Outmatch study is the study that got Zolair omalismab approved by the FDA to be used for food allergy. Um, and I'll also put a link to an article I wrote last year for my Food Allergy Pediatric Hub, which is a non-allergist doctor-focused resource. Um, it it really has so much good information. I write a newsletter that's specifically for pediatricians, nurse practitioners who are caring for kids who have food allergies, but they're not living day in, day out in the allergy space. So this is like general pediatricians. Um, and so last year I wrote an article titled, Is Zoleir superior to OIT for treating food allergies? Because last year the big headline was, oh, this study shows that Zole air is superior to OIT for treating food allergies. And I just do not believe that that is the case. And we'll talk about why. This year's press release was omalismab is as effective as multifood oral immunotherapy for allergenic food tolerability. And the big takeaway is that more than 60% of participant dietary consumption plans showed no significant difference between omalismab and multifood oral immunotherapy success rates after 12 months. But why some people are in the camp of omalismab is better than OIT is because omalismab, you basically you get your shots or shots, depending on and it's it's depending on your dosing. Um, and you don't have to do all the effort and have the risk of the updosing and the dosing of every day with OIT. And if you just look at it like that, like, oh, well, yeah, I don't want to risk having a reaction. Of course, I'm just gonna do a shot, then like, yeah, I get it. Why you would think that, well, this shot is so much better than OIT. But let's really dive into the study some to see is the shot better than OIT? And spoiler alert, I don't necessarily think the shot is better, and I don't necessarily think that OIT is better. I don't necessarily think SLIT is better. I don't necessarily think um avoidance is better. What is best is what's the right treatment plan for the patient. The right treatment plan might be omalismab, it might not be. The right treatment plan might be oral immunotherapy, it might not be. Um so I think we all need to get away with what's best, right? Until we have a cure. A cure. A cure is something where you have the condition, you apply the treatment, the condition goes away, you remove the treatment, and the condition doesn't come back. Now, what they are suggesting strongly in this article in the Outmatch study is that when you get the food in the diet with Zolair on board, then most kids are able to tolerate the food indefinitely while on Zolar. And then even when you stop Zolaire, a lot of kids are able to tolerate a lot of their allergen to a point of freely eating, which is very awesome. That is very cool. It's not all kids, though. And we don't have the long-term data to really show, okay, this is a sustained unresponsiveness. Sustained unresponsiveness means that you've undergone undergone some form of treatment for your food allergy, and then you've stopped the treatment, and then you have an ingestion challenge, meaning you eat the food again and you don't have any allergic reaction. Now, with homolysmab, they they didn't do a, okay, well, let's stop the food now. They stopped the zolar. They said, okay, keep eating the food. And a lot of kids were doing great. Though when you look at the chart, over time, it does seem like some of that tolerance is going away, meaning kids are not tolerating the food anymore, meaning kids are reacting. Not ideal, right? Nobody, no one in my world wants to be in the seat of saying, oh, your kid might react, right? Like we want to live in as much certainty as we can, and we can't always live in certainty, during which time we are having shared open communication, very transparent, about the risks, benefits, and alternatives of a potential treatment plan. So, what I talked about last year, and again, I'm gonna put a link to this article. Um, and also if you don't subscribe to the Joyful Living newsletter, which is my parent focused newsletter, then subscribe to that at foodallergyandyourkiddo.com, because I'll have a link to this in the newsletter coming up too. So basically, the way the Outmatch study worked, there were three stages to it. And I won't belabor this. Go back and listen to the other podcast on this from last year. You you really should, and you're gonna love this article on Food Allergy Pizza. I'm a very visual person, so I put some good visuals in it. But basically, how the Outmatch team studied whether or not, or how Zolar and Omal how Zolair and OIT compared to each other, it was really in stage two of the study where everybody got omalismab for a total of eight weeks. And then after this kind of like run-in to have omalismab on board, then the kiddos, the subjects, um, were stratified into one of two cohorts. Um, the multi-allergen OIT, and they continued omalismab injections for eight weeks. And then they continued the OIT, but then they went to placebo injections for 44 weeks. So they had more zolair, and they started OIT, real OIT, not placebo. The other group, they started placebo OIT, continued omalismab also for another eight weeks. But then after those eight weeks, they went to a placebo OIT and just omalismab. So then what happened? Well, then the results were in the intention to treat analyses, subjects who received zolair and placebo OIT were significantly more likely to meet primary outcomes, meaning if they did zole air and the placebo OIT, so they weren't really doing OT, they were just doing placebo, they were more likely to reach the primary outcome, which was to consume about 4,000 milligrams of all three foods. To put that into perspective, that's about a tablespoon of peanut butter. A serving size of peanut butter is two tablespoons, is about seven grams or seven thousand milligrams. So this was a little bit more than half of that. Still like legit. That's great, right? That's that's awesome. Um, that's a lot of peanut butter. Um now that group, the oh, the zolair versus placebo OIT, um, they were more likely to eat a lot more peanut butter than they were when they started. When they started, they could, they couldn't even eat a whole peanut without reacting. Um, now that's compared to people, the kiddos who received OIT and placebo zolair. However, that's the intention to treat. Intention to treat means, okay, these are the actual, these are the numbers of kiddos who who did the study. And we're gonna include all the kids who even had to stop the study because of reactions, which about half of the kids in the OIT group had to stop because they were reacting to the OIT. When you look at the per protocol, though, so those kids who were able to tolerate the OIT protocol, they did just as well as the kids who did solar. So what's up with the OIT protocol? Like, well, clearly this is saying that OIT is is not is not a good option. Well, that's when the devil is in the details, right? So when you really look at how was OIT defined? How was it planned? What was the OIT protocol? It is not a protocol that anybody doing OIT uses. It was a very aggressive protocol. And I have a great side-by-side um on this on this article that compared the Outmatch OIT protocol to Palphorsia, which yes, palphorosia is going away, but palphorsia really like made the framework of a great foundation for how to do OIT. Is it perfect? No. But is it probably the most well-studied OIT protocol? Yeah.

unknown 11:38

Yeah.

How Tolerance Actually Builds Over Time

Supermarket OIT And Personalized Care

Key Takeaway And Closing Guidance

SPEAKER_01 11:39

So let's call Palforsia's protocol sort of the the standard. In Palforzias protocol, you do an escalation day, which means you in one day, you do 0.5 milligrams of the allergen, and then you wait a little bit in the office, then you do one milligram, then 1.5, then 3, then 6 milligrams. And to put this in perspective, this is palforsia. This is for peanut allergy. In one peanut, there's about 250 to 300 milligrams of peanut protein. So in this palphoria protocol, which is one of the most well-accepted OIT protocols in the world, you start with 0.5 milligrams, you do this little escalation day, which we can talk about the science of that and whether that's necessary. My point is your the max dose that day is six milligrams. You end up consuming about 12 milligrams, still significantly less than an actual peanut, right? And then your updosing, come in the next day, you start your updosing at three milligrams. You do three milligrams every day for two weeks. And no sooner than two weeks, come back in the office, you go up to six milligrams, then 12, then 20, then 40, then 80. And you stick with not increasing it more than 40 milligrams. 40, 80, 120, 160, 200, 240, up to 300 milligrams. And that's the maintenance dose because that's about one peanut. And the whole concept with palphorsia when it was being developed was well, let's get kids to being bite-safe, meaning if they ate a peanut, they wouldn't have a severe life-threatening allergic reaction. So if you're doing 300 milligrams of peanut protein every day, that's the equivalent of one peanut. Okay, so that is one escalation day and 11 updoses. And this is palphorsia. OIT allergists do variations of this. But I'll tell you, this about 11, 10, 10 to 15 steps, updosing to about 300 milligrams, keeping kids on 300, 500 milligrams. Sometimes allergists go up higher for maintenance. Sometimes we get kids to a maintenance and then space out updosing to then get them to freely eating more quickly than if we just had them on maintenance for a year and then recheck their labs and then consider it an ingestion challenge. Like there, this isn't art. This is why medicine is an art is because you're using science to inform how you're treating the patient in front of you. All this to say even with palphorsia, like that that protocol, some kids still have reactions. Some kids, you have to step back, you have to slow down, you have to not updose instead of every two weeks, every four weeks, right? Space it out, give the immune system time. So, what did they do in Outmatch? They didn't do that. They started with dose one was three milligrams. Fine. I don't have a problem with that. I'm fine with that. But the next dose was 30 milligrams. So they didn't do three to six to twelve to forty, they went three to thirty. Oh, okay, okay. And then we're at 60. And then we're at 125. And then dose five is 250 milligrams. Dose five. We're at 250 milligrams at dose 10. And these are at least two-week intervals. The max dose for OIT in Outmatch was a thousand milligrams, which fine. I'm I'm totally down with a thousand milligrams being a maintenance dose. But I will tell you, not all kids can get there that quickly. And that's exactly what we saw in Outmatch. That even with that leading into starting OIT, they had omalismab on board. And yes, omalismab takes maybe six months-ish to get out of the system. Um so in theory, they had OIT on, they had they had Zolair on board, and then they stopped the Zolair and started the OIT. Um actually, when they started the OIT, they still had Zoleir on board for another eight weeks and then they stopped it. This Outmatch OIT protocol was way too aggressive. Now, what's very cool is half the kids tolerated it, so that's very cool. Um we can learn so much from that because we're constantly thinking about how can we make a kid's life better? How can we minimize the number of updoses a child needs? That's where we still need so much more research to answer these questions. So that, you know, if a family, if they don't need to come in for 15 updoses, they only need to come in for 10 updoses, like that's amazing, right? This aggress this protocol was way too aggressive to truly say, to truly compare OIT to omalismab. So if they were truly going to compare them, as I said last year, please do an evidence-based OIT protocol and literally compare the two. And then I I want, I want so bad that to say that we can put kids on zolear for X amount of time, get them eating their allergen regularly, and then stop the zole air, and then all of those kids who were eating their allergen will continue to be able to safely eat their allergen indefinitely. I want that so bad. I hope the data pans out to that. We're still waiting for that. But immunologically, it if the food is in the diet while someone's on zole air. So let's say we put them on zole air, that allows them to start freely eating the food. When you start freely eating the food, that, or when you start ingesting the food, that is what causes your immune system to grow tolerance to the food. Zoleir is preventing the immune system from having an allergic reaction to the food, but current state, we're not seeing where zole air is actually doing something alone to grow tolerance. Now, is it amazing when we have a kiddo who's having some reactions to their OIT and we add zole air, and then they just are cruising, they get to freely eating, they're opening their diet, and then we're starting to pull back the zole air, and then oh, maybe they're starting to have some symptoms, so let's put it back on. Let's give the immune system time while we are doing something disease modifying, which I am in the camp, that the oral immunotherapy, sublingual immunotherapy, the patches coming out, um, that these immunotherapies of allergen exposure, low dose allergen exposure over time, that that is what is growing the tolerance while Zolair is helping to support that immune milieu that the kiddo will not have reaction. So can we please stop saying one is better than the other? The best one is the one that is right for this particular child that is in front of you. And what is so amazing, and let's all come together and be really excited, that we have options now. We have options now. The other thing that struck me in this meeting is that this was this year, the way they did this presentation was very cool. Um, it was uh Dr. Bob Wood, who is contributed significantly to this field. Well done, sir. Thank you. And Dr. Karin Keat, who is amazing and I totally fangirl over her. I mean, she's done some very, very cool work, and she is his protege. He said that she was his favorite fellow. A fellow is is an allergist in training. Um, she is no longer in training, she is she's a boss. So he had the pro, like, yeah, Zola is so much better than OIT. And she had the con argument of nope, OIT is better. Um, and and these are pro-con debates that that the academy and other organizations they put on to have both sides really brought out, even though um one side might be really in the other camp, but being able to bring out the pros and the cons of everything. And what really came out not just in that talk, but in other discussions is that the definition of OIT is very different depending on who you're talking to. So some allergists who are very much in the academic world and and have not been exposed to what I call supermarket OIT, meaning go to a store, buy peanut butter, come in, we desensitize with that, um, pasteurized liquid egg whites, like real foods, like bring in the real food, and that's what we use to teach your child's immune system to tolerate it. That is still a very foreign concept to some academic institutions. Because the concept of using a non-FDA approved fill-in-the-blank food treatment, medication, whatever you want to call this, the concept of using just straight peanut butter that a mom brings from her house to desensitize a child is very like, what? We can't use a non FDA approved product. Everything has to go through the FDA. Um doctors are trained to make medical decisions. And while the FDA serves a very important part. Purpose, it does not serve the purpose of replacing a doctor's expertise. And the concept that something like peanut butter is not adequate to be used to treat a child's peanut allergy, we've got to get past that because the evidence very clearly shows that real food OIT, supermarket OIT, works. It works. Families like it. Right? I mean, there's a reason palphorsia is going away. It's not because it wasn't effective, because it was. It wasn't because of quality issues. It was it was fine. But allergists don't need it because we can use what's in the kids' pantry. So I hope you have enjoyed today's episode. Um and I'm gonna put, like I said, I'm gonna put this this article from last year where I wrote on Food Allergy PTUB, because it has the really good graphics, um, in the show notes. And I want you to take away from this episode that the right treatment for your child is the right treatment for your child. It's not necessarily the right treatment for somebody else. Somebody else's treatment is not necessarily the right treatment for your child. And every child deserves personalized, evidence-based medical recommendations. And you can have two kiddos who are both seven years old, both have peanut and egg allergies, and they need two very different treatment plans. And that's okay. And what's so amazing is that we're living in a world where we now we have omalism app, right? We have Zolair, we have OIT, we have SLIT, we have options and more options to come. God bless you. God bless your family.

SPEAKER_00 24:52

Thanks so much for tuning in. Remember, I'm an allergist, but I'm not your allergist. So talk with your allergist about what you learned today. Like, subscribe, share this with your friends, and go to foodallergyandyourkiddo.com where you can join our newsletter. God bless you and God bless your family.