Practical challenges in oral immunotherapy resolved through patient-centered care

Abstract

Oral immunotherapy (OIT) is now widely recognized as a valid option for the management of IgE-mediated food allergies. However, in real-life practice, OIT can lead to a variety of unique situations where the best course of action is undetermined. In patient-centered care, individual patient preferences, needs and values, should guide all clinical decisions. This can be achieved by using shared-decision making and treatment customization to navigate areas of uncertainty in a way that is responsive to patient’s needs and preferences. However, in the context of OIT, lack of awareness of potential protocol adaptability or alternatives can become a barrier to treatment personalization. The purpose of this article is to review the theoretical bases of patient-centered care and shared decision-making and their practical implication for the patient-centered delivery of OIT. Clinical cases highlighting common challenges in real-life OIT practice are presented along with a discussion of potential personalized management options to be considered. While the practice of OIT is bound to evolve as additional scientific and experiential knowledge is gained, it should always remain rooted in the general principles of patient-centered care.

Geographical Discrepancy in Oral Food Challenge Utilization Based on Canadian Billing Data

“…The overall increase in OFC uptake likely re ects an increase in their demand following the recent shift in practice towards a greater focus on formal diagnosis of food allergies, support to early introduction of food allergens and threshold determination prior to the initiation of oral immunotherapy 21,22 . While technically there are two clinical settings to conducting OFCs, the restriction of Quebec OFCs to hospitals ultimately did not limit the overall number of challenges completed as the number of OFCs per 100,000 residents were similar in Ontario and Quebec.…”

Information needs of patients considering oral immunotherapy for food allergy

“…Communication about the long term, (often) daily nature of treatment is critical from the beginning of therapy. 17,21 Training the family regarding support for reaction management and understanding of dose administration and modification is crucial. Clinics must, therefore, offer a means of secure communication with the OIT team to report reactions and concerns or seek guidance about dose adjustments and may include a direct pager, email or phone support, or online forms.…”

“…SDM discussions may occur in one or across multiple visits and can be ongoing throughout the treatment process. Longitudinal procedures like OIT may benefit from an ongoing SDM approach, revisited periodically as challenges arise, new patient needs develop, or alternative options become available 21 . Successful SDM necessitates a trusting, mutually communicative therapeutic relationship between the clinician, the caregivers, and, when possible (e.g.…”

Patient selection for milk and egg ladders using a food ladder safety checklist

“…Shared decision-making (SDM) refers to the process by which patients play an active role in managing their health [ 25 ] It is also a bidirectional conversation that incorporates pros and cons of approaches and integrates patient preferences into decision making. This is different from informed consent, in which patients only agree or disagree with a treatment option.…”

“…It is essential to clarify goals and expectations of treatment, experience with previous management strategies, and possible fears. In the context of food allergy, it is important that the allergist provides different options to patients and families [ 25 ]. For example, if a patient has multiple food allergies, an option of milk or egg OIT instead of ladders could be incorporated as part of a multiple food OIT protocol, which has also been shown to be safe and effective [ 26 ] Ultimately, for patients with identified contraindications such as uncontrolled asthma, or where dose adherence would be unlikely, strict avoidance while carrying an epinephrine autoinjector and future reassessment for spontaneous resolution might be a better option [ 27 ].…”