Sanjeev Jain, MD, PhD
In 2007, a longtime patient of mine, a 14-year-old boy, came to me after he had just spent his vacation in the hospital, being treated for anaphylaxis. While we didn’t know for sure how he had been exposed to the tree nuts, our best guess is that it was cross contamination from a salad bar. This was his sixth anaphylactic reaction in one year. He said that “this avoidance thing isn’t working out so well for me”.
This young man was frustrated with food allergy avoidance, and wanted to know if there was anything that we could do to treat his allergy so that he didn’t have to be so fearful and careful. Teenagers and young adults, in particular, have a hard time with strict allergen avoidance, and the constraints that it puts on their social lives.
I told him that there had been a recent study on a process called oral immunotherapy, and I had just heard a lecture from one of the authors of the study in an allergy meeting. The process of gradually building tolerance for allergens seemed to work well, and there was no reason to think that tree nut desensitization couldn’t work just as well as peanut. That said, multiple tree nut desensitization had never been studied in a formal setting, and to the best of my knowledge, he would be the first patient to attempt it.
The young man told me that he was a Star Trek fan, and that he was ready to “boldly go where no man has gone before”. His parents agreed that allergy avoidance wasn’t working, and after considerable discussion of the risks and potential benefits of treatment, we decided to begin desensitization for multiple tree nuts. I was perhaps the first medical doctor to offer desensitization treatment in private practice, and I believe, the first to do combined tree nuts in a single protocol. With the success of this treatment, he was able to freely eat nuts without any adverse reaction. With his life-threatening condition, he would not have qualified to join the military, but after the treatment, he was able to join the naval academy, and become a naval officer.
The original research on the safety and efficacy of peanut OIT was presented at the 2007 meeting of the American Academy of Allergy, Asthma and Immunology (AAAAI) by Dr. Wesley Burks and colleagues from Duke University School of Medicine and Dr. Stacie Jones and colleagues from The University of Arkansas School of Medicine. Dr. Burks has since received considerable recognition for his work on OIT, including election as the president of AAAAI in 2012. Since then, a number of prominent academic centers including Johns Hopkins University and Stanford University have conducted numerous studies showing safety and efficacy of OIT, and hundreds of articles have been published on this form of treatment in scientific journals.
The protocols that medical doctors, myself included, have developed over the past decade to desensitize patients to food allergies are all loosely based on this early study. That said, each of us have also learned from the practice of treating patients, and there are some differences in our protocols. I think that the differences reflect the robustness of the process; oral immunotherapy works remarkably well. That said, it can be challenging for many patients, especially those that are highly sensitive. The fact that there are now over a hundred medical doctors offering oral immunotherapy in private practice is also testament to its efficacy. It also reflects the desperate need of patients, who suffer from a life of strict allergen avoidance. Even with a restricted life of food allergen avoidance, accidental exposure still happens all too often.
Since the life-transformative treatment performed on the 14-year old boy 10 years ago, we have performed more OIT treatments than almost any other allergy practice in the country. We have desensitized patients to every food imaginable from nuts to milk, and soy to buckwheat. We were the first clinic to perform OIT for shrimp and a number of other foods. We have an impeccable reputation in the community due to our nearly 100% success rate on OIT after approximately 2000 treatments performed.
I remain fascinated by the latest research on the immunology of allergic diseases. In addition to oral immunotherapy, we have treated patients with sublingual immunotherapy (SLIT), and epicutaneous immunotherapy or the “patch”. All have their own limitations and benefits. We are perhaps the only allergy practice that have an integrated approach to desensitization through incorporation of every modality, and formulating a custom protocol for each patient. I go to every major allergy conference, and maintain an academic interest in the theory of immunological desensitization, and eagerly read the allergy journals. I incorporate all of the most recent findings in my treatment protocols. It is wonderful to be helping people in such a real and meaningful way.