Peanut oral immunotherapy (OIT)- one step closer to FDA approval

Many people or families affected by peanut allergy are likely aware that on Friday, September 13, 2019, an FDA advisory panel voted 7 to 2 to recommend Aimmune’s peanut oral immunotherapy (OIT) product originally identified as AR101 (now with the brand name Palforzia). Here is a link to a New York Times article regarding this. While the vote is non-binding, the FDA usually follows their advisory panel’s recommendation. If approved, Palforzia will be indicated as a treatment to reduce the incidence and severity of allergic reactions after accidental exposure to peanut in those aged 4 to 17 years of age with a confirmed diagnosis of peanut allergy. 

The data reviewed by the panel showed a 9.1% risk of anaphylaxis with Palforzia compared to 3.5% risk for placebo with dose escalations (updosing). There was an 8.7% risk of anaphylaxis with Palforzia compared to 1.7% risk for placebo while on maintenance dosing. Epinephrine use during dose escalations was 10.4% for Palforzia compared to 4.8% for placebo, and 7.7% for Palforzia compared to 3.4% for placebo while in the maintenance phase. 

Now let’s review the projected cost for the FDA approved product. Analysts have estimated the cost for Palforzia to be $4,200 a year for an individual patient. This is the cost of the standardized peanut flour alone and does not take into account the cost for office visits. Currently, the cost for peanut allergic patients going through our customized OIT program at Allergy, Asthma & Food Allergy Centers (AAFAC) is approximately $2/capsule, which would total $730/year IF TAKING IT DAILY FOR THE ENTIRE YEAR. As our peanut OIT patients know, if things are going smoothly, after approximately 16 weeks (112 day), our patients have transitioned to actual peanuts (sometimes this transition occurs sooner) for a cost of ~$224, which is obviously much, much lower than the cost of the “drug” Palforzia. Additionally, there is no recurring annual cost since patients are consuming regular store bought peanut products for their maintenance doses.  Some other practices just starting OIT this summer (2019) in the greater St. Louis area are taking another approach. Instead of billing insurance, they offer peanut OIT on a cash basis. At Allergy, Asthma & Food Allergy Centers, the typical expense to reach a maintenance dose is less than $2500, though this depends on an individual’s insurance plan (insurance companies set the amount for office visit copays and deductibles), so the out of pocket expenses could be significantly lower. Our practice goal is to ensure as much access to OIT as we can by making it as affordable as reasonably possible for our community. We know what it is like to have food allergies in our own families- the fear, the insecurity, the near constant worry when our kids with food allergies are in an environment we cannot control- which is the main reason we pioneered OIT in the St. Louis area. We have now expanded to Illinois to give even more patients and families suffering with food allergies additional options for treatment. Our office there is located at 510 Fullerton Road, Swansea, IL 62226.

So what exactly is the “drug” Palforzia (AR101)? While the FDA classifies it as a drug, it is basically standardized peanut flour in a capsule. The standardization is necessary for clinical trials and FDA approval, but there is no evidence that using Palforzia is superior to using regular peanut flour that is commercially available for OIT (as practices across the country have been doing for more than a decade). Nevertheless, we at Allergy, Asthma & Food Allergy Centers are very excited that at least some form of OIT will soon achieve FDA approval. This is a big step in giving more people a choice when it comes to managing peanut allergy, though as mentioned above, people in the greater St. Louis region have had the option of OIT through our practice since 2016, and we currently have patients going through OIT not only for peanut but also for cow’s milk/dairy, egg, wheat, soy, sesame, and tree nuts.

Oral immunotherapy is not for the faint of heart. It takes a lot of dedication and courage from patients and their families. While there are real risks, including both anaphylaxis, eosinophilic esophagitis, and lack of tolerability due to gastrointestinal issues for some patients, some of the concerns regarding anaphylaxis with OIT have been a bit sensationalized. The risk of having a serious reaction when purposely exposed to an allergen is of course higher than when trying to just avoid the allergen, JUST AS IT IS WITH ALLERGY SHOTS for seasonal/environmental allergens. However, both with allergy shots and with OIT, treatment is administered in a controlled fashion, so individuals know exactly what triggered the reaction and how much they consumed compared to accidental exposures to a food allergy. Many people have died from accidental exposures, but there are no known deaths in the U.S. associated with OIT. In fact, when a life threatening reaction occurs with OIT, there is usually an associated underlying circumstance (illness, exercise, hot showers, etc) that led to the reaction.

Going back to the example of allergy shots, you do not hear investigators, the press, or other individuals saying that allergy shots should not be administered due to the increased risk of anaphylaxis. There are generally risks with any form of medical treatment, but the potential improvement in the quality of life for an individual and family after either allergy shots (also done at AAFAC) or OIT can be HUGE, even LIFE CHANGING, as people who have been through these treatments in our office (and other places) can readily attest. While some investigators suggest that there is no evidence of an improved quality of life with OIT, we strongly disagree and address it in a previous post https://aafacenters.com/food-oit-and-quality-of-life/

Food allergy and OIT have become somewhat of a sub-specialty for allergists, and not all allergy offices will be equipped or even have an interest in offering this treatment. There are reasons for this, and this blog post from OIT 101 addresses this issue.

We at Allergy, Asthma & Food Allergy Centers look forward to continuing to partner with our patients and their families to improve health outcomes for environmental allergies, asthma, and food allergies! Thank-you for your trust and dedication!

 


Food OIT and Quality of Life

Recently, Chu et al published their analysis of randomized controlled trials of oral immunotherapy (OIT) for peanut in The Lancet. Their conclusions are worth reviewing, but it should also be made clear that at least one of the authors has long been opposed to OIT being available to the broader public outside of academic studies. You can read some of our thoughts on OIT and why academics do not approve of this treatment in of our older posts here- https://aafacenters.com/treatment-for-food-allergies-what-is-oral-immunotherapy-or-oit/

The recent analysis looked at 12 trials of 1024 patients who have gone through rigid controlled protocols for OIT and does not take into account the much, much larger number of patients who have successfully completed OIT through private practice groups such as The Food Allergy Center of St. Louis (division of Allergy, Asthma & Food Allergy Centers of St. Louis). To put this in perspective, our practice alone has over 90 patients on a maintenance dose of peanut OIT with over 80 active patients in the process of going through our customized peanut OIT program (more than 100 active patients if looking at all OIT foods), and THOUSANDS of individuals throughout the country have successfully completed OIT through private practice allergists. You can see the published data from the experience of private practice OIT allergists here- Private Practice OIT Experience.

The recent analysis determined that individuals treated with OIT have a higher risk of having food allergic reactions while actively going through OIT compared to those who just continue to strictly avoid the food allergen. This is not surprising, of course, since when someone goes through OIT, they are ingesting the food allergen and the main risk of OIT is having a reaction to that food.

The most interesting finding in the Lancet article is that the parents’ or individuals’ quality of life was not improved with OIT. While that may have been true for the people in those studies (possible reasons for this discussed below), at the Food Allergy Center of St. Louis, we know that OIT has had an incredible positive impact for patients and families with food allergies as well as ourselves. So how could the academic researchers find that OIT did not have an impact on people’s quality of life?

Here are some possible explanations.

  • Patient selection- The limited number of patients selected to go through OIT in academic studies may be different than people going through OIT in private practice. People may have different reasons to participate in a study versus going through active OIT treatment for themselves or their children. The OIT families in our practice are incredibly motivated to do what is best for their child and/or themselves. They are dedicated, cautious, and often very knowledgeable about OIT before they even come to see us.

 

  • People treated through academic OIT studies have to follow RIGID protocols that ARE NOT CUSTOMIZED to each individual. If someone going through an academic study protocol is having an adverse event (vomiting, abdominal pain, allergic reactions, etc), there are strict limitations on altering the study protocol. This is VERY different from our ability to tailor an OIT program for individuals with food allergies, especially when there are problems. This is also likely why the success rate of OIT from academic studies and from companies that are attempting to produce FDA approved OIT products are much lower  (<70% success) compared to our success rate (>85%). Our priorities are SAFETY and SUCCESS!

 

  • Approaches to OIT have changed since the initial OIT studies were done. So of course, if you include studies from over a decade ago, patients’ experiences from that time are likely very different than those going through OIT now, especially those going through OIT in private practice groups. We understand how to adapt and adjust therapy when there are any issues. We are also continually evaluating and re-evaluating our protocols to both standardize them while maintaining flexibility to customize them for each individual person in our OIT program.

 

We certainly appreciate the incredible pioneering work and time that academic researchers have invested into studying OIT. Their studies clearly show that OIT is very successful, which is why we and many of our colleagues throughout the world have dedicated themselves to bringing this life altering treatment option to those with food allergies.


Food Intolerances

There has been increasing concern regarding food intolerances over the past several years, and people are often confused regarding the difference between a food intolerance and a food allergy. Food allergies (especially the immediate type of food allergies of which most people are aware) can cause life-threatening reactions (anaphylaxis) while food intolerances are not life threatening. There are no standardized tests for food intolerances, and while companies may offer testing for food intolerances, no one actually knows what the testing means. These tests measure “IgG” antibody to foods and do not provide information about food allergies. Testing for “IgE” antibody to foods does provide information regarding food allergies.  With food allergy tests (as with most tests) there can be false positives, so these tests should never be done indiscriminately and should only be done under the care of an allergy specialist. In fact, avoiding a food that someone tolerates without any symptoms based on a positive “IgE” test alone can actually lead to the development of life-threatening food allergies, so allergists strongly advise against random food allergy testing. Since there are no standardized tests for food intolerances, and since most tests for food intolerances show many positive results that do not correlate with a person’s symptoms, the best approach for most individuals is to keep a food and symptom diary to help them determine if a food intolerance (again, not a food allergy) is triggering their symptoms.  Most patients who are healthy and have no symptoms will have IgG antibodies to one or more foods.  Our practice, Allergy, Asthma & Food Allergy Centers of St. Louis, has a very, very strong focus on FOOD ALLERGY but not food intolerances. When patients come to see us about food intolerances, we generally advise against any form of allergy testing.

 

Please follow this link to watch Dr. Vitale on the news from 2/27/19 discussing food intolerance.


Early Introduction of Peanut

Allergists have suspected for years that early introduction of foods likely decreases the development of food allergies. The LEAP (Learning Early About Peanut Allergy) study published in the New England Journal of Medicine in February 2015, definitively showed that early introduction and regular consumption of peanut (approximately 2 teaspoons of peanut butter 3 days per week) dramatically decreases the risk of developing peanut allergy by about 80%. Since the study was published, new guidelines were also released with the following recommendations:

  1. Children at the highest risk of developing peanut allergythose with severe eczema (atopic dermatitis) and/or egg allergy should have some form of testing to evaluate for the possible presence of peanut allergy. If testing is negative, home introduction or a supervised feeding can be done, and if the child tolerates peanut, they should regularly consume approximately 2 teaspoons of peanut butter at least three days per week. This process should start ideally between 4-6 months of age. If testing is positive, depending on the testing results and the comfort of the specialist, and office based food challenge to peanut may be done to determine if the infant is allergic before introduction at home is considered.
  2. Children in the moderate risk groupthose with mild to moderate eczema and no egg allergy should start consuming peanut (about 2 teaspoons) three days per week starting around 6 months of age. These children do not necessarily need testing before peanut is introduced, which can be done at home.
  3. Children at low risk for peanut allergy- those without signs of eczema and without egg allergy can start consuming peanut when age appropriate and according to family and cultural preferences.

While formal recommendation #3 does not stress early introduction, it is important to note that there is no real downside to early introduction, and delaying introduction even in those without eczema or egg allergy could potentially lead to an increase in developing peanut allergy compared to those who introduce early.

A question parents often have is how peanut can be introduced at home. The video below features Dr. Ruchi Gupta, one of the leading experts in food allergy, discussing home introduction of peanut. We hope you find this helpful!

 

 

 

If your infant or toddler is found to be allergic to peanut, do not despair. There is good recent evidence that early oral immunotherapy (OIT)/desensitization to peanut has very good outcomes (over 90% success rate when done correctly and carefully) and is safe. If you would like more information on OIT, see our Food Allergy Center of St. Louis page.


EpiPen and Mylan Generic Epinephrine Autoinjector Expiration Dates Extended for Some Lots.

Extended Use Dates Provided by Pfizer

Extended use dates to assist with EpiPen intermittent supply interruptions

[August 21, 2018] Due to the intermittent supply interruptions of EpiPen, FDA is alerting health care professionals and patients of updated dates through which some EpiPens and the authorized generic version, manufactured by Meridian Medical Technologies, a Pfizer company, may be used beyond the manufacturer’s labeled expiration date. To help ensure patient safety, these products should have been — and should continue to be — stored as labeled.

Based on stability data provided by Pfizer and reviewed by FDA, the following extended use dates are supported for specific batches indicated in the tables below. Patients that have the batch numbers below will be able to use them through the corresponding new use dates to help with supply. As data become available, this list can continue to expand.

FDA is not requiring or recommending that the identified batches in the following tables be relabeled with their new use dates. However, if replacement product becomes available during the extension period, then the agency expects the lots in these tables will be replaced and properly disposed of as soon as possible.

Please see the recent FDA in Brief for more information, and contact CDER Drug Shortage Staff at drugshortages@fda.hhs.gov with questions regarding these tables.

Epinephrine Injection, USP 0.3 mg Auto-Injectors
NDC 49502-102-02 appears on the box
NDC 49502-102-01 appears on the individual device within the box

BatchManufacturer’s Original
Expiration Date
New Expiration Date
(beyond manufacturer’s
original expiry date)
6FM7224/20188/2018
6FM7394/20188/2018
6FM7714/20188/2018
6FM7724/20188/2018
6FM7734/20188/2018
6FM7155/20189/2018
6FM7165/20189/2018
6FM7565/20189/2018
6FM7575/20189/2018
6FM7685/20189/2018
6FM7805/20189/2018
6FM7815/20189/2018
6FM7825/20189/2018
6FM7835/20189/2018
6FM7856/201810/2018
6FM7876/201810/2018
7FM1158/201812/2018
7FM1178/201812/2018
7FM1208/201812/2018
7FM1348/201812/2018
7FM1749/20181/2019
7FM1759/20181/2019
7FM27410/20182/2019
7FM27510/20182/2019
7FM27610/20182/2019

EpiPen® (epinephrine injection, USP) 0.3 mg Auto-Injectors
NDC 49502-500-02 appears on the box
NDC 49502-500-01 appears on the individual device within the box

BatchManufacturer’s Original
Expiration Date
New Expiration Date
(beyond manufacturer’s
original expiry date)
6GM4804/20188/2018
6GM4814/20188/2018
6GM5034/20188/2018
6GM5044/20188/2018
6GM5064/20188/2018
6GM5074/20188/2018
6GM5124/20188/2018
6GM6694/20188/2018
6GM5995/20189/2018
6GM6856/201810/2018
6GM7666/201810/2018
6GM7676/201810/2018
7GM0268/201812/2018
7GM0458/201812/2018
7GM0489/20181/2019
7GM0549/20181/2019
7GM1649/20181/2019
7GM1729/20181/2019
7GM1739/20181/2019
7GM2729/20181/2019
7GM19110/20182/2019
7GM20011/20183/2019
7GM20111/20183/2019
7GM20312/20184/2019
7GM20412/20184/2019
7GM21212/20184/2019
7GM21312/20184/2019
7GM36012/20184/2019
7GM36112/20184/2019

Oral Immunotherapy (OIT) For Food Allergies

There has been press recently on a “new” food allergy treatment by a company which plans to bring standardized doses of peanut flour to market so that individuals with peanut allergy can be desensitized. This has generated a lot of discussion and excitement in the food allergy community over the past month.

However, it is important to note that this is not really a “new” treatment. Recent studies on this type of treatment using peanut flour go back more than a decade, and this form of treatment has been offered for food allergies by practicing, board certified physicians in allergy and immunology (allergists) for at least 10 years. Our practice, Allergy, Asthma & Food Allergy Centers of St. Louis, has been offering this treatment since the summer of 2016, when our first patient (the daughter of one of our providers) was desensitized to peanut when she was 9 years-old. Since then, our practice has desensitized 35 children to peanut with smaller numbers for other food allergens. In addition, we have 58 children currently going through the OIT process as well.

So let’s back up a bit and review a few basic questions.

What is oral immunotherapy or “OIT”?
This is a process of desensitizing someone to a food to which they are allergic by giving very tiny doses of that food and slowly increasing the amount of the dose over time. It is a way to get a person who has life-threatening food allergy to be able to consume the food without having a reaction. This is not necessarily a “cure” for food allergies, and people need to consume the food on a daily basis to prevent reactions in most cases. They should also continue to have access to their epinephrine autoinjectors. However, promising studies suggest that some children (especially younger children) may not have to consume the food daily to be protected.

What is the primary goal of OIT? The primary goal of OIT is to prevent an episode of anaphylaxis with an accidental exposure. In other words, the single most important goal of OIT is to make it so a person who accidentally consumes a food allergen to which they are allergic does not have a life-threatening reaction.

Why did Allergy, Asthma & Sinus Care Center of St. Louis start offering OIT?
First, as mentioned earlier, one of our provider’s has a child who has had food allergies since infancy (as a side note, that provider still gets a little blame at home and has a certain amount of guilt for not having done more to prevent or treat food allergies sooner), so there was clearly a significant amount of self-interest in investigating food allergy treatment options in our practice. Therefore, our practice believes there is an urgent need in our community to offer options for the treatment of food allergies in all patients but especially in very young children. Let’s briefly talk about why we believe this using peanut allergy as an example.

The general consensus is that peanut allergy is only outgrown in about 20% of people who develop it. This means that the vast majority of children who are diagnosed with peanut allergy will not outgrow the allergy compared to the much greater chances of outgrowing milk and egg allergy for example. However, an excellent study from 2017 published in the Journal of Allergy and Clinical Immunology (“Early oral immunotherapy in peanut-allergic preschool children is safe and highly effective”) showed that 91% of children 9-36 months of age who were treated with OIT for peanut were able to successfully introduce peanut into their diet and did not have reactions when challenged even after stopping daily peanut treatment for 4 weeks! Let’s repeat that- basically 91% of kids who successfully went through OIT at a young age and then stopped consuming peanut daily, still did not have reactions 4 weeks later when challenged with peanut. That is incredibly exciting news, and this led us in 2017 to expand our OIT offering to infants who are diagnosed with peanut allergy. If only 20% of kids generally outgrow peanut allergy, and we can turn that number upside down and make it so that nearly every infant/toddler initially diagnosed with peanut allergy can start eating peanut without the risk for a life-threatening allergic reaction…..well, we feel strongly that the potential impact of this treatment in our local community is a game changer for food allergy, especially in our youngest patients. In fact, the authors of the study mentioned above concluded “E-OIT [early-OIT] had an acceptable safety profile and was highly successful in rapidly suppressing allergic immune responses and achieving safe dietary reintroduction.” One of our provider’s only regret is not being able to offer this sooner, especially for their own family.

While the focus of the previous paragraph was on younger children, this treatment clearly works for a majority of older children as well. While OIT is not necessarily the right option for everyone, and by no means do we intend to imply that everyone with food allergies should go through OIT (this is a very personal decision for individual families), we feel that families should have choices beyond just strict avoidance for the treatment of food allergies. We understand that a teenager who has avoided peanuts their entire life and is doing fine may have no interest in going through OIT, but we still feel that having the option for treatment available is important for our community.

Why don’t more allergy practices offer this?
While we cannot speak for everyone, there are likely several reasons for this.

First, we are the community experts when it comes to food allergy (in addition to being leaders in treatment of asthma, environmental allergies, hives, and immunodeficiency). In addition to offering OIT, we offer comprehensive management of food allergies. We do numerous food challenges (well over 200/year), often to rule out food allergy or to determine if someone is still (or ever was) truly allergic to that food, so that people do not need to avoid foods unnecessarily. We have been using advanced component testing for food allergies for about 10 years (initially for egg and milk and more recently for peanuts and tree nuts). This has helped us determine over the years who may be good candidates for food challenges. The wait list for food challenges at both Cardinal Glennon Children’s Medical Center and Saint Louis Children’s Hospitals is often more than 6-12 months. We had been able to get people in for food challenges within 1-2 weeks, but as more patients have found us, this wait time has started to creep up, and as we write this, the wait time can be up to a couple of months.

Second, the practice of OIT is not standardized. Most people in academic medicine feel that since we do not know the exact, best protocol and doses that should be given for OIT, it should not be offered outside of research studies. The problem with that response is that a generation of children do not necessarily have time to wait until everyone agrees on the (single) absolute best approach. Children’s immune systems are constantly developing, but the older they get, the more likely their immune systems will become “locked into” their food allergy. We know from studies not only in food allergy but also from studies with allergy shots that the earlier people get treated, the better the long-term outcomes.

Third, the broader academic allergy community feels that the risks outweigh the benefits. We have heard at allergy meetings from some key thought leaders, statements (to paraphrase) such as “people with food allergies can simply avoid the food, and they don’t have reactions. Why treat them with OIT that has the associated risk of life-threatening allergic reactions?” “Avoidance is still the best option.” “Until we have all the necessary studies, people outside of research settings should not do OIT.” Respectfully and vehemently, we disagree. Again, we recognize that OIT is not right for everyone, but it is a valid treatment option. Most (not all) people doing this research do not have children with food allergies. Some of them seem not to recognize that terror that some of us may feel when our children may be in an environment where eating something as innocuous as a small cookie can lead to an emergency department visit or even death. They don’t understand the fear that may prevent us from eating out or going to baseball games to cheer on the Cardinals. They may not know that it is not always “fun” to be one of the only or the only child sitting at an “allergy free” table at school. There are many more examples too numerous to list here of the day to day experiences families dealing with food allergies have to go through. With all of that being said, there are significant risks in OIT, including anaphylaxis and the possible development of an inflammatory condition of the esophagus called eosinophilic esophagitis (EoE; about 3-5% in published studies), and the risks may outweigh the benefits for some people.

Finally, OIT is very labor intensive, not just for families, but for allergy practices. This is not an endeavor to be entered into lightly, which is why our practice considered this for over 3-4 years, taking the time to develop the infrastructure and excellent staffing (our front desk staff, medical assistants, nurses, office management, administrative/billing, and providers are all awesome!) required to at least start offering OIT on a smaller scale. We have grown since 2016, and we hope to continue to do so in the years to come so we can serve more of the community in a safe and efficient manner. We are proud to report that some local allergy practices in the greater St. Louis area have started referring some of their own patients to us specifically for OIT, but those practices will continue to manage the other allergy/asthma health conditions of their patients.

We welcome new patients and appreciate how much we ourselves have learned from our established patients. We are not looking to dictate one treatment for everyone. We know every individual/family is different and what works for one person may not be the best option for another. We honestly feel that medicine should be a partnership between patients and providers. Our mission is to use our expertise to improve the quality of life for adults and children through the diagnosis and management of asthma, food allergies, and other allergic conditions. We look forward to working with you and your family to improve everyone’s health outcomes. As we often say to our patients during OIT treatment, remember, this is a marathon, not a sprint.


Living With Food Allergies

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A diagnosis of a life threatening food allergy is a life-changing experience for individuals and their families. While living with food allergies requires always being vigilant, having a game plan helps make it manageable. There are many excellent national and in some cases local resources to guide families living with food allergies. FARE (Food Allergy Research & Education) is one of the most prominent national groups. They have a very useful “Food Allergy Field Guide” that is geared to families newly diagnosed with food allergy and can be downloaded in PDF format. Their website (www.foodallergy.org) has a lot of resources.  Locally, the Asthma and Allergy Foundation of America- St. Louis Chapter (AAFA-STL) is a fantastic organization. While they are geared a little more toward asthma, AAFA-STL holds Food Allergy 101 meetings throughout the year and has other resources.

How families deal with food allergies varies from family to family, in part because everyone has a different risk tolerance. For example, some families avoid all foods labeled with “may contain”, “processed in the same facility”, “processed on shared equipment”, and etc., while other families may allow consumption of foods with such labels in certain circumstances. Good rules to live by are:

ALWAYS have access to epinephrine. Lack of access or delayed administration when having a serious reaction are more likely to lead to poor outcomes.

ALWAYS read labels. If a food is not labeled, and you do not know who made it, then it is best to avoid it.
Communicate effectively with friends, family, schools, and caregivers regarding the food allergy. Advocating for yourself or your family member is essential.

Traveling and eating out can present their own challenges. A recent New York Times article discussed the difficulties individuals with food allergies may have when traveling by plane. Allergy Eats is a good resource to check out when it comes to dining options.

It is important to remember that some food allergies may be outgrown, especially those to cow’s milk (dairy), eggs, wheat, and soy. Peanut, tree nut, finned fish, and shellfish allergies are less likely to be outgrown, but some individuals can still outgrow these. Therefore, regular follow up with your allergist is important. There are also new exciting treatment options currently available or on the horizon. Studies with the peanut and milk patches have been very promising. Oral immunotherapy (OIT) for foods is also an option for some individuals – but not for everyone. Our practice offers OIT with the first goal being risk reduction or significantly decreasing the risk that an accidental exposure will lead to a life threatening reaction or anaphylaxis.