Dr. Kara's Personal Food Allergy Story

Kara: One of the scariest moments in my life happened about six years ago when my nine month old ate scrambled eggs, she threw up and had hives. And as an allergist mom, I knew, "Well, crap. She has food allergy."

Today on Allergy Actually, we are gonna talk all about new treatments for food allergy.

Amber: Historically, so what was the treatment?

Kara: Yeah, So when Josie was diagnosed, she is a healthy, happy first grader now. But it was avoidance. And so we had to figure out, "Okay, can, does that mean avoiding all egg in everything, including in like muffins and cakes?" Thankfully she did tolerate egg that was in baked goods. We call it extensively heat treated egg for those in the know. But for things that were like hard boiled eggs, scrambled egg, french toast, pancakes a cookie that wasn't well baked, those were all things that we had to strictly avoid.

And we used, when we had the epinephrine auto-injectors in our case used Auvi-Q, sent two of those to the daycare, had two of those always in the diaper bag or my purse. And it really changed our lives and was pretty scary. One quick story.

Shortly after her diagnosis I was mentoring a group of first year medical students, and it was the end of the year and I had them all over for dinner. We ordered catering from the local Italian restaurant. And despite watching Food Network for years and realizing that pasta is made from flour, egg, and water and that they make homemade pasta at said, delicious Italian restaurant, I forgot.

So here's Josie with her shirt off eating the spaghetti, and I started seeing hives develop and I was like, "Oh God." In front of these mentees. Thankfully she did okay. We got her bathed, gave her some Zyrtec. We didn't, she didn't end up throwing up, so didn't feel the need to use epinephrine, but it was really like this key moment as an attending allergist of like, Okay, what, you know, I can understand the desire to want to do anything and everything to potentially help my child outgrow this or have a little more cushion for those mess ups, right? Like 

Amber: Did ever have those thoughts? "Gosh, okay. What's out there? What should, what else should we be doing?"

Kara: I'm not gonna lie. I was looking up things like the egg ladder and maybe we can talk about that in another but there is some data to say that those kids who do tolerate egg, that is baked in things that you may want to incorporate that into their diet so that they outgrow allergy sooner. And we were incredibly fortunate that she was able to tolerate those.

We kept them in her diet and by the time she was about three, three and a half, we were at the allergist office doing a food challenge and she ate scrambled eggs with an equal amount of ketchup and did fine.

Amber: Yay. Food allergy success.

Meagan: That yes. This goes into some of the treatments that I know you're offering and I wanna learn about, because I think, gosh, it really, when we talk about things that you don't feel safe in that, Ugh.

Amber: And not everybody outgrows food allergy. Like I think that's a myth out there with allergy, you know, you can grow into allergies, you can grow out of allergies. That part's true. But if you have life-threatening food allergy, each food has its own likelihood of outgrowing it. With children, milk and egg, along with peanut are some of the most common allergies, and the milk and egg most tend to outgrow it, but it's not quick. It's for the nuts, it's actually the minority of people that naturally outgrow this.

So this is something that if you're not doing active treatment, if all you're doing is preventing, because maybe that's all you know there is to do we want to let you know there is more.

Oral Immunotherapy (OIT) & Palforzia Explained

Amber: A couple of years ago, the first FDA approved food immunotherapy treatment came out on the market. It's called Palforzia for treating peanut allergy.

So this is an oral immunotherapy, it's called OIT. And with this method the indication is for achieving desensitization or bite safety essentially. So the goal is that you would take this series of initially almost microscopic amounts of peanut powder and increasing that dose over time. The first time that you start OIT, there's something called an escalation day.

So you're in your allergist office for several hours while you're starting at this dose that's low enough that most people with life-threatening peanut allergy can tolerate. And then gradually over certain time periods taking more and more gradually increasing. Then you take it home. So you're doing these doses at home and that's usually the same dose. You're not increasing the dose at home, but you're doing this daily at home for one to two weeks, depends on your treatment plan. And then you're coming back into the office for up doses, usually every two weeks.

The goal is to get you up to the maintenance dose, which is essentially eating a peanut. And this is all part of getting a patient from a place where having an accidental ingestion could take their life to a place where biting into a cookie at a party is not a big deal. And is maybe more of a signal like, oh, this has my allergen in it. So that's the FDA approved product that's out there. There are allergists that can offer OIT for other foods. So our practice does this. There's an organization called FAST that is the group of allergists that offer OIT for foods.

Sublingual Immunotherapy (SLIT) for Food Allergies

Amber: And so there are lots of other foods we can do this for, all the common food allergens. There's also a, another type of food immunotherapy called SLIT. We talked about SLIT in a previous episode for Aeroallergens, but this is the drops under the tongue for different foods. And it's, I guess I'll use the word less aggressive than OIT. Aggressive's an aggressive word, but it's lower dose, lower risk of reaction.

That one is similar in that you do initial dosing in the doctor's office and then home dosing. There's less of a buildup a little bit of an easy start. So different options in terms of immunotherapy. But there's also another medication. It isn't an immunotherapy that can be used for food allergy that sometimes people take along with their OIT or SLIT, or sometimes use it alone.

Meagan, do you wanna talk more about that one? 

Absolutely. 

The Truth About Food Ladders (Egg & Milk Only!)

Meagan: But I do wanna take a second to point out when we talk about tolerating things that are extensively heated, such as egg and baked goods and cow's milk and baked goods. Those are really the only foods I'm aware of that, that we do in a ladder. Way meaning that you can do step up. So just know that if you're allergic to peanut, you can't cook that in the oven and then be not allergic to it. Because what happens whenever we are doing that heating process and the studies typically show you're heating at 350 degrees for about 30 minutes, but it literally breaks the protein down into pieces.

And for some people, their body doesn't, they doesn't recognize those pieces and so they can eat that. And then for other people, they still recognize it and so then they can't tolerate it in a baked good. But it's important to know that those are specifically for cow's milk and egg. But one of the things that I'm not at the point yet that I'm offering any kind of OIT or SLIT for foods other than I've started a little bit with Alpha-gal which is gonna be a whole other episode.

But and I do bridging a lot and that technically, I think is a form of OIT where we try to get people to tolerance for extensively heated foods like the cow's milk and egg and baked goods. And then, get them eating that at least three times a week with the goal of outgrowing. Hopefully they're more lightly cooked or lightly prepared foods like on the stove top. The,

How Xolair (Omalizumab) Works for Food Allergies

Meagan: but the other thing that has been approved now for about a year and a half, a little over a year and a half, 

I believe it's a medicine that we have actually used for over 20 years to treat allergic asthma.

And it's called Omalizumab. That is the generic, the brand is Xolair. Just recently a biosimilar was released. And biosimilar is basically the word for generic with biologic medications. And Xolair is a medicine that it binds to that IgE protein that is in our blood that's specific for things you are allergic to.

So for instance, peanut that we've talked about a lot. And it helps that to be taken up in the blood and occupied, so it's not sitting on the receptors of the mast cells that hold histamine. And over time those receptors, because there's not enough IgE sort of sitting on them, they downregulate, which means you have less of them.

And when you then have an accidental exposure to the food, there are less receptors on those cells to activate because there's not IgE specific for the food sitting in them. So the practicality of all that basically just means that it is a shot and it's given once every two to four weeks, and that is based on what your total IgE level is and your weight. And then age is taken into consideration as well with that.

So the idea is that when you use this medication for food allergy, it is to try to get you to where if you have an accidental exposure, you have an increased level of tolerance than what you normally would whenever you are not on Xolair. So if you have an accidental bite of something, you are more likely to tolerate it.

The initial I'm not sure if initial's the right word, but a lot of the recent studies with Xolair were done actually on people who are undergoing oral immunotherapy. So it, it doesn't preclude you. That's one of my, what my patients say, is it, ask, it doesn't preclude you from doing OIT or SLIT. You can do that with it. And I have a lot of patients who have chosen and wanted to do that. The advantage is it also can help with chronic hives and asthma as well. And a lot of people, honestly, sinus disease Exactly. Polyps. And it's a very helpful medication for people who are atopic, meaning very allergic to things.

And it's something that is in the repertoire of all those foods. I feel like, or all those things for foods. I feel like we're still in the forefront of learning about all of this and there's new things that I see pop up in my feed all the time on Doximity about, food allergy and things coming up in the future.

But I'm excited at this time that I do offer it in my clinic for food allergy as well as the other things. And we have had patients as young as it's approved for one and over for foods and we have had patients that young who have started it. I've had little asthmatics who are toddlers who took it for peanut and now they're no longer having to be on an inhaler. It's just, it's a really neat thing to watch. Thank you guys for talking about all of this. I think it's neat to talk about things where we're all in different stages of figuring out what we want to do and how to use this new data and these new therapies that are out there. So if you have questions or you wanna talk about it, leave comments.

Please leave them below. Follow us, and we certainly will talk about this more in the future. And thank you for joining us on Allergy Actually. 

​