Do We Need More Pharma or More Farms to Treat Food Allergies?

Introduction

The field of food allergy treatment has been evolving rapidly, with several promising developments in recent years. Typically, much of what makes headlines, though, surrounds who pays for the headlines. Today, I want to break down some of the basics of the treatments available that allergists utilize, and also introduce some in the pipeline. More importantly, I want to pose the question of whether more pharma or farms are needed as we embark on this food allergy treatment journey.

What Is Currently in Clinical Practice?

Oral Immunotherapy (OIT)

OIT has been the most widely used treatment and has been in clinical practice for well over a decade. It involves gradually introducing small amounts of the allergen into the patient’s diet, with the goal of increasing tolerance over time. Research continues to refine OIT protocols to improve safety and efficacy.

• Effective for most allergens: peanuts, milk, eggs, wheat, soy, tree nuts, seeds, shellfish, fish, spices, and more
• Treatment typically takes 6–12 months, varying by patient and protocol
• End goals are decided jointly by patient and allergist: free-eating vs protective dosing
• Vast majority of patients are treated with commercially available foods
• Palforzia is the only FDA-approved OIT product, and only for peanut allergy

A 2023 survey of 129 private allergy practices showed >26,000 patients had been treated with OIT, the majority using retail food rather than FDA-approved products.

Sublingual Immunotherapy (SLIT)

SLIT involves placing a small dose of the allergen under the tongue. It has been more commonly used for environmental allergies but is expanding into food allergy treatment.

• Delivered via real food or allergen extracts
• Allows for flexible dosing and fewer restrictions compared to OIT
• Fewer adverse reactions than OIT
• Patients usually still avoid allergenic foods but gain protection from accidental exposure

Biologic Therapies

In February 2024, XOLAIR® (omalizumab) was approved for IgE-mediated food allergies in adults and children aged 1 year and older.

• Indicated for reducing allergic reactions (including anaphylaxis) from accidental exposure to one or more foods
• Patients continue to avoid allergenic foods
• Being studied in combination with OIT for enhanced safety and efficacy

Among available treatments, OIT is the only approach that can potentially allow patients to free-eat the foods they were once allergic to.

What’s in the Pipeline?

More Biologics

Monoclonal antibodies like dupilumab (originally developed for asthma and eczema) are under investigation for food allergy treatment.

Peanut Toothpaste

A novel oral immunotherapy method:

• Contains controlled doses of peanut protein in toothpaste form
• Used daily during brushing to gradually build tolerance
• Currently in clinical trials with promising early results

Epicutaneous Immunotherapy (EPIT)

Uses a skin patch to deliver allergens through the skin. EPIT is being studied primarily for peanut allergy, with ongoing research into safety and long-term outcomes.

Vaccine Development

Research is ongoing into vaccines that could offer long-term protection against food allergies by reprogramming immune responses.

Genetic and Immunological Research

Deeper understanding of allergy genetics and immune pathways may allow more personalized and targeted treatments.

Microbiome Research

Studies suggest the gut microbiome plays a key role in food allergy development and tolerance. Manipulating the microbiome may one day help prevent or treat allergies.

These innovations represent a shift toward more personalized treatment, but most remain in research or clinical trial stages.

More Pharma or More Farms?

After over 10 years of OIT, three key lessons stand out:

1. Food is power — Commercial foods can drive cellular-level change in the immune system, shifting from life-threatening reactions to tolerance. >95% of OIT patients are treated successfully with food, not pharmaceuticals.
2. The microbiome is power — Gut flora balance influences allergy risk and tolerance more profoundly than many pharmaceuticals.
3. Integration is power — Allergies don’t exist in isolation but within interconnected systems (immune, nervous, endocrine). Addressing root causes requires understanding these dynamics.

Many pharmaceutical approaches disproportionately focus on peanuts — “peanut privilege.” But most patients are allergic to other foods. Pharma often targets effects rather than causes, with treatments that can be expensive and inaccessible.

Biologics are a notable exception: they can enhance safety and expand access, especially in combination with immunotherapy. Still, when comparing food-based OIT to food-specific pharma products, the evidence suggests we may need more farms than pharma.

References

1. Wasserman R, Windom H, Jones D. Oral Immunotherapy in US allergy practice. JACI: In Practice. 11(12):3814–3815, 2023. https://doi.org/10.1016/j.jaip.2023.09.017
2. XOLAIR [prescribing information]. Genentech USA, Inc. and Novartis Pharmaceuticals Corporation.

‍