blog by Dr. Patricia Gomez Dinger
In June, two young patients walked through our Advanced Allergy door filled with newfound hope. These patients, just four and fourteen years old, along with their families, are optimistic that four to five months from now they will walk back out out this same door at our Stone Oak Clinic with little to no threat of experiencing a potentially life-threatening allergic reaction to cashew or walnut. That is huge.
These patients are my first ever, allergic to walnut and cashew, whom I have begun treating with Oral Immunotherapy, or, what is more commonly referred to as OIT. Over a series of months I will feed them the very protein from walnut and cashew that they are allergic to. That may sound crazy, but what OIT does is desensitize the body to an allergen so that when that allergen is ingested on a regular basis, the body does not react adversely or send a patient into anaphylaxis, a serious, rapid-onset allergic reaction that can be fatal.
Oral Immunotherapy works.
How do I know?
Since 2015, I have treated over 50 children with peanut allergy, one of the most wide-spread and dangerous food allergies, taking them through Oral Immunotherapy to an end-point where they can safely be around or even eat peanut. Over a series of months, the patient eats traces of peanut protein, gradually and methodically increasing the amount he or she eats, over time. I have watched these kids, several of whom have been hospitalized after eating peanut in the past, successfully eat 24 peanuts without even blinking an eye. As a physician and mom myself, it has been amazing to witness such relief and satisfaction from these peanut allergy families seeking a sense of freedom.
One of these peanut allergy patients who has undergone OIT with me is 12-year-old Isaih Emerick. He completed OIT for peanut nearly two years ago at the age of 10. Now, he is back ready and determined with the help of his family, to fight his tree nut allergy with Oral Immunotherapy.
“It has been very scary. Before OIT for peanut we lived in fear feeling like we were always walking on eggshells,” said Lisa Emerick, Isiah’s mom. Today, Isaih eats his daily maintenance dose of whole peanuts without any sign of an allergic reaction. And life, Lisa has told me, is very different for Isiah and his entire family. Once fearful of flying or going on long vacations to unfamiliar places, the Emericks now travel outside of the United States. Seeing first hand that OIT worked for Isaih’s peanut allergy, it was Isaih’s mom who first approached me about starting Oral Immunotherapy for tree nut.
The protocol is one started by an Allergist out of Dallas. It is also his protocol that I followed for OIT for peanut.
The OIT protocol for tree nut, specifically walnut and cashew, is a little different from that of OIT for peanut. Partly because peanuts are legumes, whereas a tree nut is a hard-shelled nut. Also, a tree nut allergy usually lasts a lifetime; fewer than ten percent of people allergic to tree nut outgrow it.
Tree nuts include, but are not limited to, cashews, almonds, Brazil nuts, pecans, pistachios, pine nuts, and walnuts. A tree nut allergic reaction can be triggered by the nut itself or by ingesting tree nut products including nut oils and butters.
Symptoms I often see associated with tree nut allergy include:
For Isaih and Luke, I have decided to attack cashew and walnut first. I am conducting OIT to treat them simultaneously. The reason for this is that these boys are both allergic to walnut, cashew, pecan, and pistachio. Walnut and pecan have cross reactive proteins. So do cashew and pistachio. Therefore, if I desensitize the boys to walnut, they will also be desensitized to pecan. The same holds true with cashew for pistachio. It is kind of like killing two birds with one stone, but in this case 2 nuts with one OIT protocol treatment.
Throughout OIT we see our patients reach several milestone days. The first milestone happens on day one when we help our patient build up or dose to reach a certain protein amount. For walnut, on day one, our patients will drink nine doses of the protein in a powder form mixed with grape Kool-Aid. The boys will also drink nine doses of cashew protein to reach the designated “first-day” dose, on which they will go home to continue on until the second week of OIT. Each week, we will gradually build on that original, day one milestone dose.
The second big OIT for tree nut milestone will happen around week seven and week ten, when the boys will eat their first whole cashew and walnut, respectively. This is always a very big deal for my OIT patients as they hold, feel, and see that whole nut. It represents so much more than a nut. It is fear. It is uncertainty. The single whole nut is a goal – something they have avoided being around their entire life and will now put into their mouth, chew, and swallow, safely.
The third and final milestone is expected four to five months into OIT for tree nut, depending on how well the patients builds up on their doses to that point. If they up-dose as expected and with no problem, around month four or five the boys will undergo the cashew and walnut challenge. This is by far the greatest challenge the boys will face during OIT. Typically families take off from school, sometimes pray before, and almost always video this final food challenge. For this nut challenge, Isaih and Luke will have to eat 8 cashews and 10 walnuts! When finished, my team and I are always there to meet the family with high fives and hugs. I also reward the patient with a little celebration to mark the milestone and send them home with a favorite snack that might include tree nut, such as chocolate covered cashews.
As the patients successfully eat all eight cashews and all ten walnuts without suffering any sign of a reaction they will officially “graduate” from OIT and go home on a maintenance dose of tree nut! The maintenance dose requires them to eat 8 cashews and 3 and a half walnuts every day to “maintain” their desensitization to the allergen. It doesn’t mean the patient is cured. It doesn’t mean he or she no longer has a tree nut allergy. He does. He will. OIT just prevents the body from suffering a reaction to it.
It is important to know that all dose increases are done in my clinic with me or my staff on hand. With each dose increase the patient has to wait in my clinic for a designated period of time where my team and I evaluate his or her breathing and look for any signs of a reaction. Should we notice any sign of an allergic reaction we are right there with the patient, epinephrine on hand, ready to administer it should we need to. Also, my Advanced Allergy Stone Oak clinic is within feet of North Central Baptist hospital. I specifically treat my OIT patients in this clinic adjacent to the hospital should anything unusual or unexpected happen. It is just one additional precaution with my chosen OIT protocol that I feel is additionally responsible and reassuring to for our patient families.
Oral Immunotherapy for tree nut is not a quick fix. It takes time. It takes discipline. It is important that the entire family be supportive of the patient and the OIT process. OIT to treat peanut allergy and tree nut allergy is also not yet FDA approved. But as a specialist who has studied Oral Immunotherapy, studied the specific protocol that’s yielding so much success in other allergy clinics outside of San Antonio, and is confident in her team’s ability to keep her patient safe, I can tell you, emphatically, that OIT changes lives for the better. After OIT, parents tell me they now feel safe flying. They share with me that they can now go on family vacations without fearing an allergic reaction, and they tell me that they actually look forward to sending their young adult away to college. Kids tell me they get to go to sleepovers, birthday parties, and sit anywhere they want to at lunch, thanks to OIT.
OIT can inspire a young person to be more courageous and do things they had once only imagined.
“I have seen such a change in Isaih since he did OIT for peanut,” Lisa Emerick told me. “He has become a more confident person.”
Please let me know if OIT for peanut or tree nut is something you would like to discuss. My team and I would love to have the opportunity to share what we know and the results we have experienced, firsthand, with you. We have blogged about peanut allergy quite a bit online. Click here for additional stories and videos. You can also find a wealth of information, patient stories, and videos on our Facebook page and Instagram Account.
In Health & Love,
Dr. P. Dinger