Safety and Effectiveness of bypassing oral immunotherapy buildup with an initial phase of sublingual immunotherapy for higher-risk food allergy.

BACKGROUND: Due to its favourable safety, sublingual immunotherapy (SLIT) for food allergy has been proposed as an alternative treatment for those in whom oral immunotherapy (OIT) is higher-risk - older children, adolescents, adults, and those with a history of severe reactions. Although safe, SLIT has been shown to be less effective than OIT.

OBJECTIVE: To describe the safety of multi-food SLIT in pediatric patients aged 4-18 years of age, and the effectiveness of bypassing OIT buildup with an initial phase of SLIT.

METHODS: Patients 4-18 years of age were offered (multi) food SLIT. Patients built up to 2mg protein SLIT maintenance over the course of 3-5 visits under nurse supervision. After 1-2 years of daily SLIT maintenance, patients were offered a low-dose OFC (cumulative dose: 300mg protein) with the goal of bypassing OIT buildup.

RESULTS: Between summer 2020 and winter 2023, 188 patients were enrolled in SLIT (median age: 11 years). Four patients received epinephrine (2.10%) during buildup and went to the emergency department, but none experienced Grade 4 (severe) reaction. A subset of 20 patients had 50 low dose OFCs to 300mg protein and 35 (70%) OFCs were successful thereby bypassing OIT buildup.

CONCLUSION: In combination with very favourable safety of SLIT, with no life-threatening reactions and few reactions requiring epinephrine, we propose that an initial phase of SLIT to bypass supervised OIT buildup be considered for children in whom OIT is considered higher-risk.