What is a food challenge?

Oral food challenges generally consist of a gradual feeding of the test food under close observation. The test usually results in a definitive conclusion about whether the food was tolerated. Oral food challenge serves two roles in managing food allergies: to confirm diagnosis of a specific food allergy and to determine if an identified allergy persists or has resolved. Oral food challenges are generally performed by gradually feeding the test food under supervision, with personnel and emergency treatments available in the event of anaphylaxis. A successful oral food challenge requires ingestion of a meal-sized portion of the tested food prepared in its usual state. It is uncommon for subsequent reactions to occur if the feeding was tolerated. 

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What is OIT?

Management of food allergy consists of strict avoidance of the food allergen and treatment of accidental exposures with medications. OIT involves daily feeding of gradually increasing doses of the food allergen until a daily maintenance dose is reached. One of the appeals of this therapy is that much of the dosing can be done at home. Allergic reactions to OIT are common, particularly during the build-up phase of dosing, and occur at higher rates in patients on OIT than those avoiding the food. Oral and gastrointestinal symptoms are the most common, followed by lower respiratory symptoms (eg, wheeze). Anaphylaxis is uncommon but occurs more frequently in patients on OIT than in patients who avoid the food. Systemic reactions may occur at previously tolerated doses, particularly in the setting of exercise or viral illness. 

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What is peanut OIT?

While peanut OIT is effective in increasing supervised in-clinic food challenge thresholds (ie, desensitization), it increases the risk of anaphylaxis, other allergic reactions, and need for epinephrine. In addition, there are considerable burdens and costs associated with peanut OIT, including clinic visits for supervised dose escalations, an indefinite period of treatment, the continued need to avoid peanut in the diet, costs of the standardized peanut OIT powder, dosing restrictions (eg, timing, type of food it can be ingested with), and the need to avoid potential triggers of an allergic reaction (eg, hot showers). Many patients are unlikely to be good candidates for peanut OIT, either because they already have a threshold that is high enough to make accidental ingestion reactions unlikely or the adverse effect profile and daily commitments required for therapy outweigh any potential benefit of increasing the reaction threshold.