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June 5, 2014

Food Desensitization and SLIT

Question

Food desensitization by SLIT is supposed to reduce the degree of sensitivity. Can we introduce SLIT for food in our routine practice? If permitted what is the suggested dose of MD/M?

Answer

By Dr. Wesley Burks:

SLIT as a treatment for food allergy has been associated with successes for kiwi, hazelnut, peach, milk, and peanut allergies. The best trial to date has evaluated SLIT in children with peanut allergy in a randomized, placebo-controlled trial. Subjects receiving peanut SLIT safely ingested more peanut during OFC than control subjects (1710 vs. 85 mg, respectively). Side effects were predominantly oropharyngeal, and epinephrine was not administered during the trial. Immunologic changes at 12 months included decreased skin prick test response size, basophil activation, and IL-5 levels with an increase in peanut-specific IgG4 levels. In a peanut SLIT trial from the CoFAR group, 70% of subjects receiving peanut SLIT were responders compared with 15% of subjects receiving placebo SLIT. The amount of peanut consumed in the peanut SLIT group increased from 3.5 to 496 mg from baseline to the 44-week OFC, respectively, with 95.2% of doses being symptom free, excluding local oral-pharyngeal symptoms. Median peanut-specific IgE levels decreased in the peanut group compared with those in the placebo group, and basophil activation did not change.

These studies show that peanut SLIT can safely induce some degree of clinical desensitization and immunomodulation among treated subjects. A consideration for the future is that the small volume, thus rendering this route of food immunotherapy more challenging if higher maintenance doses are needed to maximize efficacy, limits the maximal dose administered in SLIT. Further study is needed regarding the clinical efficacy of SLIT while maintaining its preferable safety profile.

Whether the current research with SLIT or OIT treatment for food allergy can only achieve desensitization (tolerating higher amounts of ingested food while on treatment) or can achieve tolerance has not been answered.  Much work needs to be done to answer this important question.

 

References:

  1. Excerpted from "The changing CARE for patients with food allergy" by Jones et al. in the January 2013 issue of the Journal of Allergy and Clinical Immunology.

Wesley Burks, MD
Chairman and Chief Physician
Department of Pediatrics
University of North Carolina
Chapel Hill, North Carolina, USA


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