Introduction
Addressing Misinformation in Food OIT
Shared Decision-Making in Food Allergy Therapy
Protocols from Key Research Studies of OIT
Study/type | Number of active OIT | Age in years median (range) | sIgE (kU/L) median (range) | Product used | Starting dose (mg protein) | Initial dose escalation (IDE) | Steps to maintenance (after IDE) | Frequency of build-up | Maintenance (mg protein) | Time to maintenance (weeks) | Percent reaching maintenance | Anaphylaxis or moderate/severe reaction rate due to OIT | EoE symptoms reported proportion of subjects |
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
(a) Peanut | |||||||||||||
Anagnostou 2014; RCT cross-over | 99 total: 49 active, 50 control cross-over to active | 12.3 (8.1–16.3) | 37.9 (0.35–3649) | 12% lightly roasted, partially defatted peanut flour (Golden Peanut Co, Alpharetta, GA) | 2 mg | No | 9 | Every 2–3 weeks | 800 | 24 | 84–91% | 1% (1/99) subjects Epi [0.01% (2/17,793) doses]; 22% (21/99) wheezed [0.41% (7/17,793) doses] | NR |
Vickery 2017; DBPC RCT preschool | 37 active: 20 low-dose, 17 high-dose, 154 matched controls | 2.3 (1.8–2.9) | 14.4 (3.4–48.6) | 12% lightly roasted, partially defatted peanut flour (Golden Peanut Co, Alpharetta, GA) | 0.1 mg | 7 doubling doses every 30 min up to 6 mg | 17 low, 27 high | Every 2 weeks | 300 vs 3000 | NR | 81% (30/37) total; 85% (17/20) low; 76% (13/17) high | 17% (36/211) moderate, no severe reactions. 3% of subjects (0.5% of events) required Epi | 5.4% (2/37) subjects withdrew due to chronic GI symptoms, 1 with EoE on biopsy |
PALISADE 2018; DBPC RCT | 372 | (4–17) | 61 (17–179 IQR) | AR101 characterized peanut flour with 50% protein content (mg) (drug) | 0.5 mg | 5 doubling doses up to 6 mg | 11 | Every 2 weeks | 300 | 24 | 79% (294/372) | 4.3% vs 0.8% severe; 14% vs 6.5% Epi | 4.3% (16/372) withdrew due to chronic GI symptoms; 1 with EoE on biopsy |
Blumchen 2019; DBPC RCT | 31 | 6.6 (4.8–9.8 IQR) | 89.5 (6.9–217 IQR) | Light roasted peanut flour (12% fat, 50% protein) from the Byrd Mill Company (Ashland, Va) mixed into a “ready-to-eat” chocolate pudding | 0.5–30 mg based on reactive dose (RD) during OFC | OFC starting with 3 mg, 1 dose every 2 hours up to 300 mg on day 1, then up to 3000–4500 mg on days 2 and 3 if tolerated | 33 | Every 2 weeks | 125–250 (based on reactive dose during entry OFC < or ≥ 300 mg) | 52 (40–56) | 50% reached maintenance; 74% (28/31) tolerated 300 mg OFC | 23% (7/30) subjects vs. 16% (5/31) controls with Grade 4–5; 0% Epi | NR |
Davis 2022; Open-label high-dose | 15 | 8.7 (6.2–12.2) | 62.5(0–568) | 12% lightly roasted, partially defatted peanut flour (Golden Peanut Co, Alpharetta, GA) | 1.8–750 mg based on RD during OFC | DBPC OFC with 10 doses starting at 0.5 mg up to 2000 mg cumulative to determine RD, then starting dose determined by RD, minimum 1.8 mg | 26 | Every 2 weeks | 3900 | 52 (50–71) | 71% (12/17) | 53% (8/15) subjects Epi; 2.5% (30/1188) doses severe | 0% |
Jones 2022 (IMPACT trial); DBPC RCT preschool | 96 | 3.3 (2.6–3.7 IQR) | 54 (28–192) | 12% lightly roasted, partially defatted peanut flour (Golden Peanut Co, Alpharetta, GA) | 0.1 mg | 5 doses every 30 min up to 6 mg | NR | Every 2 weeks | 2000 | 30 | 61% (59/96 ITT) | 22% (v 0%) required Epi, 42% (v 8%) moderate, 5% (v 0%)severe | 3% (3/96) |
(b) Hen’s egg (HE) | |||||||||||||
Burks 2012; DBPC RCT | 40 | (5–18) | 10.3 (3.7–231.1) | Raw egg white (EW) powder (Deb-El Food Products): 0.8 mg protein in 1 mg powder | 0.08 mg | Dosing began with 0.1 mg raw EW powder, followed by an approximate doubling every 30 min up to 50 mg. Median IDE dose 18.5 (range 6–50) mg egg powder | NR | q2 weeks | 1600 | 40 | 45% reached 2000 mg by 10 months, 82% by 22 months (15% discontinued OIT due to adverse events) | 2.5% (1/40) | 7.5% (3/40) withdrew before 5.5 months due to intermittent abdominal pain and/or vomiting |
Dello Iacono 2013; RCT | 10 | 6.6 (5–10.2) | 23.30 (8.9–35.5) | Undiluted raw HE emulsion (45 mL of raw HE and 150 mL of amino acid-based infant formula) flavored with vanilla | 1 drop (0.015 mL) undiluted raw HE emulsion | No | 26 slowly escalating doses of raw HE at home (1 drop–1 mL = 10–50%) alternating with 5 dosage doubling in hospital | Weekly at home or in the hospital | 40 mL of raw HE emulsion roughly corresponds to a small egg | 24 | 0% active reached maintenance. Median MTD was 20 mL; (range: 5–30) | 0% grade 5 reactions; 75% (40/53) had grade 3–4 reactions; 30% controls had grade 3–4 reactions to accidental ingestion per Sampson’s classification | NR |
Meglio 2013; RCT | 10 | 8.4 (4–17) | 11.3 (5.6–150) ovalbumin sIgE | Raw HE (mixed EW and yolk) | 0.27 mg | No | 181 | 1–6 days at home; initial dose administered under observation | 13,600 per week; (corresponds to 3 eggs per week) | 30.7 (25–41) mean (range) | 80% vs 20% | 0% | NR |
Escudero 2015; RCT | 30 | 7.8 (2.9) mean (SD) | 6.4 (1–245) | 3600 mg of dehydrated EW (OVOSEC SA, Valladolid, Spain) is equivalent to one medium size EW and contains at least 78% protein (2808 mg) | 0.08 mg | 12 doses given every 20 min up to 140 mg (cumulative dose of 280 mg) EW protein | 9 starting with MTD | Weekly | Maintenance: 1 egg every 48 h plus no egg restriction in the diet | 32.5 days (median) since most children tolerated a cumulative dose of 280 mg during IDE. Per protocol 9 weeks. 3 children needed > 12 weeks | 93% (28/30) reached maintenance | 3% (1/30) required epinephrine for rhinitis, urticaria, and mild resp distress during build-up after a 2404 mg dose. 6.3% (5/79) of reactions in build-up phase were classified as “respiratory distress” | Two children (7%) were withdrawn from the study for non-severe repeated allergic reactions (abdominal pain and vomiting) during build-up. These two patients had EW-sIgE levels of 5.6 and 245 kU/L, respectively |
Akashi 2017; RCT | 18 | 5 (4–11) | 19.5 (7.2–46.2) | Dry HE powder (425 mg egg protein in 1000 mg dry HE powder) based on protocol by Patriarca (2003), per authors | 0.0425 mg | No | 26 | q3–4 days at home; no observed doses | 1700; (equivalent to approx. 1/4 raw egg) | NR | 56% | 5% (1/18); one 4y subject had 2 episodes of anaphylaxis to OIT and withdrew | NR |
Pérez-Rangel 2017; RCT high-dose rush OIT | 19 | 10.4 mean (2.6 SD) | 5.6 (0.28–1735) EW sIgE | Dehydrated EW (OVODES NM, Nutrición Médica SL, Madrid, Spain) | 175.5 mg EW protein (range, 0.3–1404 mg) median initial dose of the build-up phase. Minimum dose 0.3 mg EW protein | Rush OIT: minimum 0.03 mg EW protein for those reacting to 1st dose of DBPCFC (start dose based on MTD in DBPCFC), 2–5 doses per day over 5 days to a dose of 2808 mg EW protein | 11.6 (9.39) mean (SD) of doses per patient (range, 2–42 doses) for rush protocol | 1 hour | 2808 | 3 days (1-14) | 94% (31/33) reached maintenance, 91% continued 5 months | 6% (2/33) of subjects 1.3% of doses | 3% (1/33) discontinued due to chronic GI sx |
Itoh-Nagato 2018; RCT rush OIT multicenter, parallel-group, delayed start | 45; 23 early-start; 22 late start | 7 (5–12) | 35.9 (1.2–201.6) | 1000 mg raw EW powder = 8000 mg EW | 1/10th of RD during DBPCFC: 10 mg (1–50) EW powder | Starting with 1/10 of RD, doses increased 120–150% every 30 min for 3–5 doses per day, up to 1000 mg of EW powder | None. Rush protocol only—protocol not published | 30 min | 1000 mg EW powder plus 1 scrambled egg every 1–3 days, plus ad lib | NR | 100% tolerated > 1000 mg EW powder after rush OIT and 3 months of maintenance | 4.4% (2/45) subjects discontinued due to anaphylaxis (1 during DBPC OFC) | 8.8% (4/45) discontinued due to chronic GI sx |
Martín-Muñoz 2019 SEICAP 1; RCT; OIT (pattern based on center) vs control | 88; 12/25 control started OIT after 12 mo observation | 7 (6–9) | 6.44 (0.22–2045.00) | Pasteurized EW from Guillen, Valencia, Spain (Jurado-Palomo, 2010) | 0.11 mg | Starting with 1 mL of a 1/1000 water solution of pasteurized EW, double doses every 30 min over 8 doses up to 0.4 mL of undiluted pasteurized EW (44 mg protein) | 96 (7–329) median (range) total doses during buildup phase | Daily and/or weekly | 3300; 30 mL pasteurized EW every 1–2 days | 14 (1–47) days median induction period | 84.2% (64/76) vs 16% (4/25) controls | 3.5% (15/420 reactions) severe | NR |
Pattern 1: build-up weekly in-hospital PLUS daily at home | 21 | 6.9 (6.1–8.7) | 2.90 (0.40–25.10) | -
| 0.11 mg | See above | 65 (27–154); 9 (4–22) hospital; 55 (23–136) home | 30% weekly observed plus 5% daily home build-up | 3300; 30 mL pasteurized EW every 1–2 days | 9.3 (3.9–22) | 96% (25/26) | Epi: 3.8% (1/26) | NR |
Pattern 2: build-up weekly in hospital only | 55 | 7 (6–9) | 7.4 (0.2–227.0); p = 0.007 | -
| 0.11 mg | See above | 125 (7–329); p = 0.02 | 30% weekly observed build-up | 3300; 30 mL pasteurized EW every 1–2 days | 18 (1–47) p < .000 | 75% (47/62); p = 0.01 | Epi 9.7% (6/62); p < 0.05 | NR |
(c) Cow’s milk (CM) | |||||||||||||
Longo 2008; RCT | 30 | 5–17 | > 85 kUA/mL | CM | 5 drops of 1:10 CM dilution | 36 doses over 10 days in hospital of 7 dilutions of CM starting with 5 drops of 1:10 dilution, up to 20 mL undiluted CM | > 100 | Every other day at home if tolerated | 150 mL | 52 | 36% | 7% | NR |
Skripak 2008; DBPC RCT with subsequent open label for placebo | 19; 13 DBPC RCT [6 open-label, minimal data reported] | 9.3 (SD 3.3, range 6–17) | 34.8 kUa/L (range, 4.86–314 kUa/L) | Dry nonfat powdered CM | 0.4 mg | 8 doses over 1 day starting with 0.4 mg of CM protein, approximately doubling doses every 30 min to a maximum of 50 mg (cumulative dose, 98.7 mg). Participants had to tolerate a minimum dose of 12 mg | 8 | Every 7–14 days | 15 mL (33 mg/mL) | 8 to 16 | 92% (12/13) of active and 100% open-label | 31% (n = 4) of subjects (1% of doses)—2 during IDE and 2 during home-dosing | NR; 2 subjects in active group accounted for 2/3 of all GI-related symptoms, both mild abdominal pain not requiring treatment |
Pajno 2010; single-blind placebo-controlled RCT | 15 | 4–12 | 32.7 (8.8–124.6) | CM | 1 drop of 1:25 CM | No | 18 | Weekly | 200 mL | 18 | 77% | 20% (3/15) | NR |
Martorell 2011; RCT | 30 | 6.6 (6.5–8.0) | 15 (3.35–48.7) | CM | 1 mL of 1:100 CM | 10 doses over 2 days of 3 dilutions CM starting with 1 mL of 1:100 dilution, up to 2.5 mL undiluted CM | 16 | Weekly | 200 mL | 16 | 90% | 7% | NR |
Salmivesi 2012; DBPC RCT with subsequent open label for placebo | 28; 18 DBPC RCT; [10 open label] | 6–14 | 0.7 to > 400 IU/mL | Pasteurized 2.5% fresh CM | 0.06 mg; 1 drop of 1:25 CM (20 drops = 1 mL) | No | 136 | Every 1–3 days at home, weekly in office | 200 mL | 23 | 86% | 0% | 7% (2/28) discontinued OIT on days 11 and 42 due to abdominal pain |
Lee 2013; RCT | 16 | 7–12 mo | 16.8 +/− 12.1 (mean) | CM | 16.7 mg; 0.5 mL CM | 5 doses in 1 day q 30 min starting with 0.5 mL up to 2 mL | 22 | Weekly | 200 mL | 24 | 88% | 13% | NR |
Nagakura 2021; RCT | 33; 17 heated milk HM; 16 unheated milk UM | HM: 7.6 (5.2–11.2); UM: 6.1 (5.3–10.8) | HM: 56.0 (4.3–2630); UM: 55.2 (12.5–745) | HM: CM powder, prepared by heating CM at 125 °C for 30 sec and spray-drying for 3 sec. 1 packet of CM powder dissolved in 30 mL = 6 mL CM (0.2 mL CM / 1 mL HM); UM undiluted CM | Start at half the RD of the DBPCFC. 0.1 mL CM or 0.5 mL HM | No | 8 | Monthly at home | 3 mL CM / 15 mL HM | 32 to 52 | HM 94%; UM 75%; (p = .17) achieved desensitization to the equivalent of 3 mL CM | Anaphylaxis: 0.02% doses HM; 0.05% doses UM; Moderate/severe sx: 0.7% doses HM, 1.4% doses UM; respiratory symptoms: 1.2% doses HM, 2.6% doses UM; p < .0001 | 3% (1/33, from UM group) discontinued OIT because of eosinophilic esophagitis at 1 month |
(d) Wheat | |||||||||||||
Sato 2015; open label rush high-dose OIT | 18 | 9 (5.9–13.6) | > 100 (2.92–> 100) | 200 g boiled udon (Japanese wheat noodles that contain 5200 mg of wheat protein; Tablemark, Co, Ltd, Tokyo, Japan) | 50 mg | 10 steps starting with an OFC at 50 mg building up to 5200 mg wheat protein. Dose increased q5h BID over 5 days | 20 | Weekly at home | 5200 | 20 (up to 2 years) | 89% (16 /18) | 5.5% (1/18) subjects treated with Epi; 0.04% (3/5776) doses considered severe | 5.5% (1 of 18) withdrew due to chronic abdominal pain |
Nowak-Węgrzyn 2019; RCT low vs high dose | 46; 23 low-dose; 23 placebo cross-over to high dose | 8.7 (4.2–22.3) | 88.4 (5.2 to 101) | Vital wheat gluten (VWG) is a high-protein content (71%) substance since wheat flour is too bulky. Administered in vials, capsules, scoops—depending on the dose | 0.07 mg | 8 doses | 15 steps to low-dose. 18 steps to high-dose. Including IDE: 23 steps to low-dose, 26 steps to high-dose | 2 weeks | 1445 (low-dose); 2748 (high-dose) wheat protein | Up to 44; 34 for low-dose; 40 for high-dose; median | 83% for low-dose, 57% for high-dose after 1 year | Low-dose year 1: 0.04% of doses caused severe AR, and 0.08% of doses required epinephrine; year 2 none were severe or required epi. High-dose: 0.01% of doses were severe, and 0.07% were treated with epinephrine | 4.3% (1/23) low-dose withdrew due to mild abdominal pain and vomiting. 9.5% (2/21). High-dose withdrew due to EoE or intermittent GI sx despite PPI and H2 blocker |
Nagakura 2020; Prospective observational of low-dose OIT with historical control | 16 | 6.7 (5.8–10.7) | 293 (4.5–3340) | 2 g boiled udon noodles (5 cm) contain 53 mg wheat protein | 2.7 mg | Starting with half the threshold dose of OFC, 8-step increase to 53 mg. The first 5 steps occurred once daily in-hospital, subsequent increases at home every 5 days | 8 (including IDE) | Daily × 5 days in hospital (IDE), then every 5 days at home | 53 mg | NR | 88% (14/16) | 31% (5/16) subjects; 0.1% (7/5857) vs 0% doses; 5 of 7 occurred during build-up | 0% |
Nguyen 2023; Retrospective review of multi-food OIT in academic center | 4 | NR | NR | Wheat flour | 1.3 mg | Each food was introduced separately during an IDE. First 3 doses administered every 20 min up to 10 mg wheat protein | 10 to 16 | 2 weeks | 2000 | NR | 0% (0/4) reached maintenance by publication | 0% | NR |
(e) Tree nuts and seeds | |||||||||||||
Walnut | |||||||||||||
Elizur 2019; Prospective cohort with observational control | 55 | 7.9 (6–9.7) | 6.4 (2.5–19.8) | Walnut flour (Wellbees, Monsey, NY) finely ground in a coffee grinder until a homogenous paste was generated, mixed with mineral water 25 mg/mL. Whole walnuts used after 150 mg protein dose reached | 0.1 mg | 2 consecutive days with 7–8 doses given every 10–30 min up to 300 mg | NR | Monthly | 4000, then maintained on 1200 | 24 | 89% (49/55) | 20% Epi in clinic (< 1% doses), 15% Epi at home (< 1% doses) | 5% (3/55). Dose decreased, then built up to maintenance |
Erdle 2023; Prospective, registry of multi-tree nut OIT in preschool children | 31; 19 single TN; 12 multi-TN | 1–5 | ≥ 0.35 kU/L or ≥ 5 if never ingested | 5 g protein /30 g flour; 3g protein/240 mL milk | 1–10 mg | No | 8 to 11 | 2–4 weeks | 300 | NR | 97% (30/31) | 3% (1/31) | 3% (1/31, on walnut/cashew OIT) |
Nguyen 2023; Retrospective review of multi-food OIT in academic center | 27 | NR | 33.5 ± 28 | Flour | 1.3 mg | Each food was introduced separately during an IDE and build-up. First 3 doses administered every 20 min up to 10 mg of walnut | 10 to 16 | 2 weeks | ~300 | 22 | 89% (24/27) | 0% | 1 patient with recurrent vomiting had a negative evaluation for EoE (unclear which foods) |
Cashew | |||||||||||||
Elizur 2019; Prospective cohort with observational control | 50 | 8 (6.2–10.8) | 4 (1.5–8) | Cashew flour (Wellbees, Monsey, NY - 800 mg flour contains 144 mg protein) or whole cashews | 0.1 mg | 3 consecutive days with 5–8 doses given every 10–30 min up to 3960 mg or until MTD identified | 18 | Repeat IDE monthly starting with MTD | 4000; then maintained on 1200 | 52 (12–228) | 88% (44/50) | 18% clinic, 6% home | 4% (2/50). Dose decreased, then built up to maintenance |
Erdle 2023; Prospective, registry of multi-tree nut OIT in preschool children | 66; 58 single TN; 8 multi-TN | (1–5) | ≥ 0.35 kU/L or ≥ 5 if never ingested | 5 g protein /28 g flour 4 g protein/240 mL milk | 1–10 mg | No | 8 to 11 | 2–4 weeks | 300 | NR | 94% (62/66) | 7.5% (5/66) | 3% (2/66, 1 on walnut/cashew, 1 on cashew alone) |
Nguyen 2023; Retrospective review of multi-food OIT in acadmic center | 35 | NR | 27.7 ± 31.4 | Flour | 0.8 mg | First 3 doses administered every 20 min up to 3.2 mg cashew | 10 to 16 | 2 weeks | ~300 | 27 | 83% (29/35) | 22% (8/24) required Epi during IDE. 1 severe reaction to IDE requiring 2 epi and hospitalization | NR |
Hazelnut | |||||||||||||
Moraly 2020; Retrospective | 100 included in analysis; 168 started | 5 (3–9) | 5.5 (IQR 1.7–20.9) | Ground hazelnut | 0.7 mg | Increasing doses (twice the cumulative dose) were administered every 20 min to a maximum cumulative dose of 1635 mg or RD | 11 steps to maintenance | Increase monthly from 1/10th to 1/8th to 1/6th to 1/4th to 1/3rd to 1/2 RD up to 1635 mg | 416 | 24 | 34% at 6 months | 0% | 0% |
Erdle 2023; Prospective, registry of multi-tree nut OIT in preschool children | 8; 1 single TN; 7 multi-TN | (1–5) | ≥ 0.35 kU/L or ≥ 5 if never ingested | 5 g protein /28 g flour 2 g protein/240 mL milk | 1–10 mg | No | 8 to 11 | 2–4 weeks | 300 | NR | 100% | 0% | 0% |
Nguyen 2023; Retrospective review of multi-food OIT in academic center | 10 | NR | 30 ± 27.5 | Flour | 2 mg | First 3 doses administered every 20 min (final dose NR) | 10 to 16 | 2 weeks | ~190 | 26 | 100% (10/10) | 17% (2/12) required Epi during IDE | NR |
Almond | |||||||||||||
Erdle 2023; Prospective, registry of multi-tree nut OIT in preschool children | 2 (both multi-TN) | 1–5 | ≥ 0.35 kU/L or ≥ 5 if never ingested | 6 g protein /28 g flour 5 g protein/240 mL milk | 1–10 mg | No | 8 to 11 | 2–4 weeks | 300 | NR | 100% | 0% | 0% |
Nguyen 2023; Retrospective review of multi-food OIT in academic center | 2 | NR | 19.7 ± 14.1 | Flour | 2 mg | First 3 doses administered every 20 min up to 10 mg almond | 10 to 16 | 2 weeks | ~230 | 17 | 100% (2/2) | 0% | NR |
Macadamia | |||||||||||||
Erdle 2023; Prospective, registry of multi-tree nut OIT in preschool children | 1 (single TN) | (1–5) | ≥ 0.35 kU/L or ≥ 5 if never ingested | 2 g protein /28 g flour 1 g protein/250 mL milk | 1–10 mg | No | 8 to 11 | 2–4 weeks | 300 | NR | 100% | 0% | 0% |
Sesame | |||||||||||||
Nachshon 2019; Open label OIT | 60 | 7.5 (5.8–11.6) | NR | < 240 mg doses used standardized high-protein sesame extract (HPSE), then Tahini (1 g = 240 mg sesame protein) | 0.3 mg | 2 consecutive days with up to 7 doses given every 15–60 min up to 4800 mg sesame protein or until the RD identified. Then 2 additional days with 2–3 doses per day confirming MTD for home dosing. | 14 doses total, including IDE | Repeat IDE monthly × 3 starting with MTD, then monthly increase by 50% | 4000 then maintained on 1200 | 26 (15–52) | 88% (53/60), 95% partial (240 to < 4000 mg) | 16.7% pts in hospital, 8.3% pts at home needed Epi | 5.7% (3/60). Dose decreased then built up to maintenance |
Nguyen 2023; Retrospective review of multi-food OIT in academic center | 12 | NR | 24.4 ± 16.9 | Flour | 2 mg | First 3 doses administered every 20 min up to 7 mg sesame | 10 to 16 | 2 weeks | 375 | 28 | 75% (9/12) | 25% (4/16) required Epi during IDE. 1 with severe anaphylaxis (abdominal pain, facial flushing, and change in demeanor) requiring Epi × 3 and transfer to PICU | NR |