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After treating nearly 700 food allergy OIT patients, a common theme during initial office visits surrounds not just safety but the “risk of reactions” during OIT. Many parents state their child has not had anaphylaxis for years. Others will say reactions occur regularly. Some parents say their children’s allergy testing done at an outside allergist’s office labels them as “high risk” for reactions. This leaves a lot of uncertainty in the discussion.

My discussion with patients and families focuses on the TPIRC model of OIT. The comprehensive nature of analysis not only involves elaborate allergy testing. It also involves a clear evaluation of all allergic systems of the body.   These systems involve the skin, the blood vessels, the lungs, the heart, the liver, and more. It is most important to evaluate all these systems due to the involvement of these systems during different types of allergic reactions. But while all systems are critical, the lungs are one of the most important.

As a board certified pulmonologist, my bias toward excellent lung function prior to starting OIT is based on evidence. A large Australian study published in 2014 brought to light the risk factors of reactions during allergic food exposure. The study, entitled: Safety and clinical predictors of reacting to extensively heated cow’s milk challenge in cow’s milk-allergic children., sought to define the clinical “risk factors” of children allergic to milk who were about to undergo a baked milk challenge. 71 children with confirmed milk protein allergy were set to undergo a baked milk food challenge. Keep in mind the baked milk challenge is not done all at once. It is done in a graded, staged fashion over hours of time with small incremental dose increases. Of the 71 children tested, most passed (51 total, 73%). Of the 27% who did not pass, 4 children actually needed an epinephrine injection to rescue them.

This Australian group studied these 27% who did not pass by comparing them to those who passed and discovered the top “risk factors” associated with having an allergic reaction during food dosing:

  • Any history of asthma, especially asthma requiring preventer therapy (inhaled steroids, singulair)
  • IgE-mediated clinical reactions to more than 3 food groups (separate groups ie nuts, milk, peanut)
  • A history of cow’s milk reactions consistent with severe anaphylaxis

What is the take away message?

If you are considering OIT and your child has the “risk factors” mentioned above, do everything possible to control the lungs before and during treatment. The TPIRC model not only deploys state of the art lung function testing including complete body plethysmography, forced oscillation testing, exhaled nitric oxide and lung clearance index testing. The TPIRC model of OIT ensures patients undergoing OIT are maintained at a normal to super normal level of lung function.

The questions brought forth by this study need to be studied clearly in OIT patients. TPIRC and its OIT model is actively studying these clinical questions and looks forward to publishing its data in 2016.

 

Inderpal Randhawa, MD

 

Reference:

Ann Allergy Asthma Immunol. 2014 Oct;113(4):425-9. doi: 10.1016/j.anai.2014.06.023. Epub 2014 Jul 22.

 
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Back to School on Oral Immunotherapy:  Prevention is Key!

by Dr. Inderpal Randhawa, M.D.

Food Allergy FullSizeRender

After treating nearly 600 patients with oral immunotherapy for nearly a decade, I am often asked what worries me the most.  From a parent’s standpoint, I would imagine the anticipated response will be a severe anaphylactic reaction during a visit updose/challenge or a severe reaction at home.  However, I believe in security during OIT.  Hence, the hospital based therapy and food challenges.  Similarly, the dosing protocols which limit the risk of a significant reaction to under 1 percent.  So what worries me the most with OIT?  The month of September.

September is back to school month.  After a predictable summer, the children on OIT now return to a bastion of bacteria, viruses, pollutants and more.  This is fodder for the immune system to react to.  It is most common, in my experience, to see a surge of mild reactions during home based therapy in September.  My advice is the same every year.  Prevent what you can and notify your physician prior to any OIT dosing if you see any signs of infection or increased inflammation.

The most common illnesses in September include:

  • Viruses (simple to complex colds)
  • Wheezing/Bronchitis
  • Sinusitis
  • Pharyngitis (strep throat)
  • Otitis media (ear infections)
  • Skin infections (pustules)
  • Gastroenteritis (diarrhea/vomiting)
  • Conjunctivitis (eye/eyelid infection)

What can you do to prevent a difficult September for your child?

  1. Lots of handwashing
  2. Use a safe nasal washing system after school daily
  3. Talk to the school teacher about sanitizers, wipes, and handwashing for all children
  4. Enforce the sick child policy (so sick children are sent home)
  5. Obtain a lung function test prior to school starting to ensure maximum lung function
  6. Monitor and limit activity on high pollution days
  7. Ensure your child’s technique for inhalers and nasal sprays is correct
  8. Avoid unnecessary visits to high risk areas (busy grocery stores, daycares, etc.)
  9. Apply the wash and change routine to all children and adults in the home. Many studies show the most common carrier of viral and bacterial pathogens are adults and older children.  The first thing to do when you get home?  Change clothes and wash down (hands, arms, neck, and face) with soap and water.
  10. Ensure a healthy classroom (refer to the American Lung Association healthy classroom checklist).

As always, if your child is ill during OIT, notify your doctor immediately PRIOR to dosing. 

Hopefully this September will be a smooth transition for all OIT patients.  Stay healthy!

 
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