Misconceptions, Myths & More: What Dr. Tom Chacko Wants You to Know About OIT

Transcript Disclaimer:
This transcript was generated using AI software from the original podcast audio and may contain errors, omissions, or minor inaccuracies. It has been lightly edited for readability. Please refer to the full podcast episode for the most accurate representation of the conversation.

Thomas Chacko, MD: 0:00

I I have patients routinely crying tears of joy in my office because they're, as you know, they're so nervous about it. It's really held them. It's, it's changed them. And I'm like, look, you're gonna come in my office and eat two or three peanut M&Ms and, and you'll be cool. And, and, and why do I say that because I've done it a hundred times. And then the mom is getting emotional. Sometimes they come with the grandparents. It's, so, it's been really, really fulfilling.

Speaker: 0:25

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence.

0:46

Welcome back to the Don't Feed the Fear Podcast. Last episode, we got a deep dive with Dr. Doug Jones about what oral immunotherapy is and how it works. Today, I've invited Dr. Tom Chacko here to talk to us about mostly what OIT is not, because if there's one thing that creates overwhelm in allergy treatment decisions, it's misinformation. Dr. Chacko is an allergist based in Atlanta. You also probably know him from his online presence on Instagram, and in both of those places, he spends a significant amount of time answering the same questions over and over again. Dr. Chacko is known for being direct, thoughtful, and practical in his responses. So in this episode, he helps us to break down the myths he hears the most often in his practice and online and explain how he helps families think through their real options, avoidance, OIT, biologics and beyond. If the expansion of allergy treatments has left you feeling confused, skeptical, or pulled in different directions, I have created this whole season of episodes to help to guide you and to separate noise from the nuance. So I hope that you'll enjoy.

Amanda Whitehouse, PhD: 1:50

Dr. Chacko, thank you so much for coming here on, don't Feed the Fear to talk to us about all things OIT.

Thomas Chacko, MD: 1:55

Happy to be here. It's fun. I'm glad you reached out.

Amanda Whitehouse, PhD: 1:57

Awesome. For people who don't already follow you or aren't familiar with you, tell us a little bit about your professional history and how you ended up getting into OIT.

Thomas Chacko, MD: 2:06

So I am an allergist in the Atlanta area. I started my own practice in 2019, and I, I've been doing OIT, Since probably 2015, both when I was in the hospital system and then when I was on my own. I actually inherited a patient from Dr. Hugh Wyndham, who's one of the lead guys in OIT, down in Sarasota, Florida. And he trained me, actually he was with my, my attendings. He's like, Tom, I got someone, can you take care of it? I was like, what are you talking about, we're not supposed to be doing this? But Hugh, Dr. Wyndham, I knew was always a upstanding guy and it's all about trust, right? So I trusted him. I knew he was good. He knew, he told me, Hey, you should really look into this. And that was my first patient, probably 2014, 2015. I did a lot of research on it. I presented to Emory, I presented to fellows. I present a lot, and then I started offering it shortly thereafter.

Amanda Whitehouse, PhD: 2:56

And what's your experience with it been? Now you've been doing it for a while, what are you seeing?

Thomas Chacko, MD: 3:01

It's a game changer. It's probably the fun, the most fun thing I've done in allergy. I I have patients routinely crying tears of joy in my office because they're, as you know, they're so nervous about it. It's really held them. It's, it's changed them. So to tell them that, Hey, your fear of flying, or your fear of being peanut in the air. And I'm like, look, you're gonna come in my office and eat two or three peanut M&Ms and, and you'll be cool. And, and, and why do I say that because I've done it a hundred times. Like, yeah, so, so to me, and then the mom is getting emotional. Sometimes they come with the grandparents. It's, so, it's been really, really fulfilling.

Amanda Whitehouse, PhD: 3:37

Well, yeah, and I'm smiling as you're saying the word fun because I agree with everything you're saying. I would say exciting. I personally, I wouldn't call it fun, but I get what you're saying. To be able to offer to go from a field where there really wasn't much you could do to help your patients to now have this treatment that will absolutely change their lives. It's amazing.

Thomas Chacko, MD: 3:54

And there's very few things we have in medicine, especially now, and, and the data's really good coming out in 2019, 2020, that you could really change their long-term trajectory. Like a lot of medicines, we do treat the disease and, and you gotta stay on the medicine, but this can theoretically reverse it and really change a kid when you started at 1, 2, 3, or four. For when they're in high school. If you started early, you could really make a long-term benefit. Where, where you know, I tell 'em they're gonna fire me. They might not need me by the time they're in kindergarten.

Amanda Whitehouse, PhD: 4:25

That's one of the things that I wanted to talk about, because I think people have a lot of misconceptions and fears and there's misinformation, and that's kind of what I wanted to focus on with you today, starting with what you just said. We know the younger you are the more effective it can be on the immune system, but I think a lot of people say, oh, I'm too old now. My kid's 15, they're out of the window. Or I'm an adult. It's not worth it now that I'm adult. What do you say to patients like that?

Thomas Chacko, MD: 4:47

We used to think that maybe five, six years ago, but the newer data states the age shouldn't be the deciding factor, one. It probably has to do what your IGE level is like if your IGE is two or three and you're 12, we could still reverse that. So it depends what that number is and it depends on how much it bothers you. So we have options for adults as well of teenagers, and we might adjust it. This is the biggest thing that I want you to know. All OIT is not the same. And it's not one, one thing fits all right? So you gimme a teenager whose IG is greater a hundred. No, I'm not gonna have that kid eating peanut butter jelly, but can I have them protect from accidents? Yeah. Shouldn't be that hard. So I think everyone lumps food introduction, oral immunotherapy as one thing, but it's really individually based, based on what bothers the patient and the parents and what their goal is. And we could tailor it to that.

Amanda Whitehouse, PhD: 5:39

That's such a great point because I think those decisions or those hesitations people have are based on the idea that the only goal or the only worthwhile outcome is if I can outgrow and I can freely eat it, and that there's still so much benefit to be had from developing any amount of tolerance I would think.

Thomas Chacko, MD: 5:56

Yeah, and we could do it so that hey, we give you a layer of protection. So now you are not gonna eat a peanut butter jelly sandwich, but let's pretend you're going to Thai food and you're worried about that. Where, all right, we got you covered for a little bit of peanut, or let's say cashews bother you and so we can't have you eating five cashews, theoretically, let's say it's older and their number's super high, but we could have you go to Indian food and not worry about the cashew and the curry because we have you at a layer of protection. So it just, it just depends on what bothers the patients, what's their goal, and we could tailor that.

Amanda Whitehouse, PhD: 6:24

Yeah. And then that makes me curious about that idea that our people are too sensitive. If their numbers are really high, is it still a possibility for them to, to develop, to have some benefit from doing the treatment? I,

Thomas Chacko, MD: 6:36

100 percent you and, and I know you, you follow us on our social because I get that question. Probably once a

Amanda Whitehouse, PhD: 6:42

yeah.

Thomas Chacko, MD: 6:42

My numbers are too high and that's why I say it on our social very specifically, if you follow us, I'm very specifically showing the numbers because we got a ton of Joey's who are a hundred who peanut's greater than a hundred and we still get them eating a decent amount. And there's new data actually out of Canada. This is great that if you even low dose, long-term, even if the numbers are super high, can still slow roll it and make the IGE go down. I say that because it's not an absolute no at all, and there is, there's really good data that even low dose can have long-term benefit.

Amanda Whitehouse, PhD: 7:14

I love that and I want doctors on here saying that, but I like to always throw in my personal experience that my son successfully completed for multiple peanuts and tree nuts, and he was one of those kids with sky high numbers, super sensitive. You know, we didn't even know what he was reacting to half the time, and he did it safely and amazingly well. I like to have the doctors back me up on it, but I think a lot of parents like me are scared away thinking, oh, I'm too sensitive, or my numbers are too high. So thank you,

Thomas Chacko, MD: 7:39

I get, I get that question. Maybe once or twice a week. Uh uh, and so that's why I wanna be very clear. There is no number too high. Uh, and, and it just depends on what you, what your goal is. And there is data that it's more, the longer you do it, the better the benefit.

Amanda Whitehouse, PhD: 7:55

And I think now that I'm in it, it's easy for me to say it's no big deal. It's just a part of our day. We've been doing it for years now, but that's another thing that scares people away, is I have to eat this every day for forever. So what do you say to those people,

Thomas Chacko, MD: 8:08

Answer is true, but the thing, the answer is true. You gotta eat every day. But the, honestly, the earlier you start, the better. Because if you start them in, like little ones like toddlers, they don't have any aversion. They'll be fine. And, and they'll, they won't mind

Amanda Whitehouse, PhD: 8:20

right.

Thomas Chacko, MD: 8:21

it's a bamba puff, it's a peanut M&M who doesn't wanna eat peanut M&Ms, right? Like you that, and then the trade off is, but then you got the middle schoolers or the high schoolers who they've developed this aversion often. And so we just tell them, we go a little lower. We just have, you have one peanut M&M that's your medicine. When you say you have to eat it every day, it doesn't necessarily have to be every day, but at some consistent interval, maybe two, three times a week. Um, we have one or two peanut M&Ms. And, and generally I'm like, if you ask me, I eat cashews and peanuts every day, like that's my protein bar, you know, that's my snack. So we just need to get it into your diet and hopefully an, uh, at an amount that doesn't bother you that much.

Amanda Whitehouse, PhD: 9:00

Right. And I think there are so many forms of it now that, that I've seen so many families work with their doctor to find a way that they can tolerate it. But I would argue, and I'm curious if you would agree, a lot of that, what you're describing with the older kids is more about the anxiety and the mental health side of that fear they've developed every day I have to eat this thing. I'm terrified of it. Do you see that as well?

Thomas Chacko, MD: 9:22

I would tell'em. Yeah, in the beginning, for sure. In the beginning, for sure. Especially when we started and I'm like, and I have to tell'em, we have patients, I know you don't know this, but I know the numbers and I know typically at these numbers, you should not react. Like it's extremely rare. So I do, I have to do a little coaching. I'll tell'em that. Honestly. I tell'em we've had hundreds of patients and that's part of the reason why I do social media. I'm like, look at, look at this kid. Look at Camden. His numbers look at did look at, so I show them examples and those numbers to try to get them to buy in. That's actually part of the reason why we do that, some of the case presentations. So they could kind of, um, they could relate with similar patients.

Amanda Whitehouse, PhD: 10:02

Yeah. It makes it relatable. I think it's so effective that this is an actual kiddo sitting here with their actual parents who were probably so scared and look at where they're getting with the support, with someone who's confident about, about the treatment. It's amazing.

Thomas Chacko, MD: 10:15

Yeah, like just yesterday, I had someone who avoided Twix, avoided ice cream, avoided Menchie's, Menchie's is big here in Atlanta, because they're worried about cross contamination, and I'm like, look, I want you next time you're eating one peanut M&M Now, they came in yesterday and ate peanut M&M for the first time. I'm like, you're good now. I want you next time to tell me how all these good things taste. And so it's fun.

Amanda Whitehouse, PhD: 10:36

What else do you do in terms of helping them work through that anxiety, especially at those early stages when it is a nerve wracking process?

Thomas Chacko, MD: 10:44

Um, it's tough. It's actually tough 'cause these kids are smart.

Amanda Whitehouse, PhD: 10:46

Right.

Thomas Chacko, MD: 10:47

Especially talking about, you're talking about a 13-year-old kid or 15-year-old kid who've been told to avoid forever

Amanda Whitehouse, PhD: 10:54

Yeah.

Thomas Chacko, MD: 10:55

and Right. And they might have seen some story on social media of someone who got, was a kiss and someone passed away and so, so they're smart. It's in their head. So it takes a little bit. It does. But then I just have to try to tell'em we've been doing, hopefully they get confidence in us, and try to, try to get that to go over to them. And then I'm like, we've done this a lot. We know the numbers and I tell'em we're doing it very slow. We're microdosing. So, so the data would show that, and our experience will show that you don't react to these doses. So kind of trying to get them to buy in, trying them, trying to get them, um, to see other stories. And then hopefully, eventually over time they'll, they'll be okay.

Amanda Whitehouse, PhD: 11:30

I feel like I know you already so well because I, I watch you. But your, your style with your patients just seems so confident, yet relaxed, not confident in a, like I know everything, just do what I say way, but. Let me help you understand and get on board with what I know will work for you. I think that relationship is so important in terms of trusting your doctor and getting a good feeling of what they're sharing and what they're recommending for you.

Thomas Chacko, MD: 11:53

I, I think so. And, and that confidence didn't come in the beginning to 10 years. Right? I needed that first two. You wouldn't have, and you know, he sent it to me in 2014. I was nervous, but now I've gotten thousands. I've done it really well, and I, and I, I'm gonna talk to you like you're my cousin or my cousin's kid.

Amanda Whitehouse, PhD: 12:08

Yeah.

Thomas Chacko, MD: 12:08

that every time and I'm like, this is what I would do if you're my cousin or my cousin's kid, and I got you. You'll be good. And I, and I, and I just walk in with that because I, I believe it. Like that's what I believe.

Amanda Whitehouse, PhD: 12:17

And I'm sure they can feel that. I'm sure that comes across, you know, people are good at reading people.

Thomas Chacko, MD: 12:23

Yeah. Hopefully, uh, we've done it a while, right? We, we've had the luxury of, of now having so much experience in the southeast doing this in hundreds, maybe thousands of patients. So, so, and, and I, let be very clear, man, I don't speak like that with everyone. There are some complicated cases, but 90%, 95% we're really good at it.

Amanda Whitehouse, PhD: 12:40

Can you tell us about when is it more complicated?

Thomas Chacko, MD: 12:43

Okay, so probably the more complicated ones are the wheat allergy ones. 'cause the wheat, I, I've done hundreds of peanuts, maybe thousands, hundreds of cashews, pistachios, and now over the past three to four years, I've done hundreds of milk and egg, and so we've gotten really better at it. I've probably done in the tens or, or maybe 50, 60 a wheat. So that one we're still working on, and I'm not saying not to do it, but we'll just have that conversation. But the other ones, we've done so much that, that we feel really good with those cases.

Amanda Whitehouse, PhD: 13:10

Okay. Another one of those big ones that people feel like they're the exception is this question of EoE. What do you say to those patients?

Thomas Chacko, MD: 13:19

um, first off, I'll say the question is how. What's the food that you're allergic to and how much it bothers you avoiding. that's my first question. for example, if I have a 13-year-old peanut allergic kid. Who has a history of EOE that may or may not be stable and they're like that child, we just avoid peanuts and we live our best life. I'd probably just say continue avoidance. 'cause it doesn't bother you.

Amanda Whitehouse, PhD: 13:40

Right.

Thomas Chacko, MD: 13:41

Um, but now if you tell me you, it really has anxiety, it bothers how you go out, you can't go with your friends, then I'm like, we can do it. Um, with, even with a history of EoE, as long as that's been stable, um, but we might aim for lower doses. And then the data of EOE with, with OIT is there, but there's also good data that if you slow it down or go lower, allow the body to tolerate it more, the EoE-like reactions with OIT can get much better. So it's just a matter of, of trial and error and, and, and working with the patient, working with their symptoms and, um, finding something that works, but it's doable. Just takes a little bit.

Amanda Whitehouse, PhD: 14:18

Good. I think that's really important for people to hear. I really want people to hear that because that's one thing I hear a lot, well, we can't do it, we have EoE. Or what about the parents who are avoiding because they're, they're afraid of triggering EoE even if the child doesn't have any history of symptoms or a family history.

Thomas Chacko, MD: 14:32

I just don't see it that often. And if it is, we slow it down, you know, or, or we treat, or, um, typically you slow down the treatment and make and make sure we don't up dose. We just stay at the same dose for the next two, three months, and then leave it at that, and then go up as needed.

Amanda Whitehouse, PhD: 14:46

So even if you were the rare case, were that to happen, it's not a horrible disaster. It's not a non reversible, awful worst case scenario.

Thomas Chacko, MD: 14:54

So that's a great question, Amanda. The, the data would state that if you have it and you stop the treatment, you go back to how you were. So if worse comes worse, you just stop it. And, and, and that's an option if it continues. But usually we can treat through it.

Amanda Whitehouse, PhD: 15:04

Okay. What about other reactions? And obviously that's a, just a fear in general. There can be some symptoms and people are really afraid of having a reaction during the process.

Thomas Chacko, MD: 15:14

So, so the biggest thing I probably see is belly issues. Stomach issues. That's probably the biggest. Like, it upsets their stomach. They're intolerant. Have I had severe ana, like anaphylaxis? Rare. But there, you know, I've been doing this 15 year thousands of patients. Of course we're gonna see some, um, but generally if you go really slow, we're micro doing, so we're giving tiny. We're not giving five peanuts. We're giving tiny tiny amounts. And generally I'm saying 80, 85% goes maybe 90, 95% goes uneventful. I tell'em, I probably only hear from about 5% of my OIT patients, uh, because 95% they sail through.

Amanda Whitehouse, PhD: 15:51

Just sailing along. Yeah, and I, I can throw in there even as a parent who my son did have anaphylaxis during OIT and I, it was still worth it. Still do it. It was still life changing for us. Obviously it was scary. it's still, to me, it's not a deal breaker because you can still get to where you want to go.

Thomas Chacko, MD: 16:07

And can I ask you, when did your son do it? Age and how long ago?

Amanda Whitehouse, PhD: 16:11

So he, he started when he was six. He had been actually in a peanut patch clinical trial before that, and anaphylaxed to the patch. He was very sensitive. Like he's, he's a very reactive kiddo. He was in maintenance by age 10 for peanuts, cashews, and pistachios.

Thomas Chacko, MD: 16:27

And the reason why I asked that and why it's, why I think it's relevant is I'm going to assume his numbers were super

Amanda Whitehouse, PhD: 16:33

Mm-hmm.

Thomas Chacko, MD: 16:34

Yeah. So I'm gonna get, he's one of those ones that are probably a hundred or something that you asked, right. If I had seen him four or five years ago, um, let's pretend you came to me. Uh, I would put him at a higher dose and then that is a higher risk of reaction. He had a reaction. Now, the new data, maybe we could leave him low, less reactions and still get to the same endpoint again. I'm not, that was, that's, if I had even seen it myself four or five years ago, I would've aimed for like six peanuts, eight peanuts. Now, even the past two, three years were like lower, less reactions, still kind of get you to the same endpoint. So my point, we've gotten better over the past five or six years, um, than what we, we just learn more as studies and data come out.

Amanda Whitehouse, PhD: 17:14

Of course the more data you have. Um, and it's absolutely not a knock on our doctor. He was great too, but I like people to know that like, it's okay. You get, you'll get through it. I'm curious about people coming to you for a lot of second opinions. A lot of people don't have a doctor around who offers OIT or their doctor maybe has talked them out of it or said, here's why I don't offer it. What do your conversations look like with people about that?

Thomas Chacko, MD: 17:38

So I, I would tell you first of all, many training programs won't teach about OIT just 'cause that's not what they might do in their academic institution. So the Dr. may just not be familiar with it. Um, it takes a lot of time, it takes a lot of resources, it takes a lot of manpower and experience. And some people are just like, it's just not our thing. And they don't have an interest in doing it, so they don't offer it. Um, it's not a knock on your allergist, it just might not be their thing. Um, but doesn't mean it's not your thing or your patient's thing. So that's why I'm concerned about that. Again, I always talk, if it was my cousin, I'm like, yeah, your doctor might not do it. Um, or, or they might be taught to do some of the biologics or the patch or other thing. Just because they don't do it doesn't mean it's not the right thing to do. So I'm always saying just get a second opinion so you know what options are out there. And OIT is not always the right answer. You know, you might be 13 and avoiding peanut and live your best life. Avoidance is fine. But you should be aware of what's out there. I, I would say, which may be different from what other people say. I would say if you're an infant and if you're eight months, one year, two, three years, I would say there's harm in not doing the treatment because I think you could really reverse that train. And if you don't do it, you could lose that window. So, so I do say if your allergist told you you're peanut allergic and they just said, just avoid, I think that that. You might be hurting yourself if you don't do a treatment. It's kind of hard statement. I don't wanna insult another doctor. But again, that's what I would say to my cousin or my cousin's kid. And so I just try to stick with that.

Amanda Whitehouse, PhD: 19:08

Yeah, I can see that and it's, it's easy for me to say as a parent on the other side of it, but obviously had I had that opportunity and knowing what I know now, I used to watch the parents who had, you know, a, a. A toddler or a, a younger baby in the room and think, oh my gosh, how are they doing this? Like, I'm having a hard time with a five or 6-year-old. But now knowing what I do, like the opportunity to completely reverse and outgrow, it's, it's amazing. So yeah, I hope people will hear it and take that point home.

Thomas Chacko, MD: 19:33

Yeah, because remember Amanda, the thought is that between one and four, their IgE goes up like that, right? And so when they're five, six, their IgE is gonna be that 60, 70, 80, but it hasn't gotten there yet by their one or two. So it's really easy to intervene before it shoots

Amanda Whitehouse, PhD: 19:47

Right.

Thomas Chacko, MD: 19:48

And so that's why we try to get it then.

Amanda Whitehouse, PhD: 19:50

Right, right.

Thomas Chacko, MD: 19:51

So from a medical point of view, let's, let's, let's play a, another thing that you hear about eczema patients,

Amanda Whitehouse, PhD: 19:55

Mm-hmm.

Thomas Chacko, MD: 19:56

And baby eczema, and they're like, oh, we should avoid these foods. My eczema gets better. That drives allergies crazy we know that there's a window that you avoid. You might have them develop food allergies if you don't introduce the food. So

Amanda Whitehouse, PhD: 20:10

Right?

Thomas Chacko, MD: 20:10

want

Amanda Whitehouse, PhD: 20:10

Yep.

Thomas Chacko, MD: 20:11

babies, our atopic babies, avoiding foods like we know. That's kind of like the wrong decision. You know, so I would argue to say, Hey, if your kid's peanut allergic and they're, uh, 12 months old and you don't intervene, I wouldn't say it's the wrong decision, but you're, it's gonna be very difficult to reverse. It's gonna be more difficult to reverse that train. If you wait. So that's, that's my, Hey, some things we know are right, some things we know are wrong

Amanda Whitehouse, PhD: 20:38

Yeah.

Thomas Chacko, MD: 20:38

it's, oh, you'll call.

Amanda Whitehouse, PhD: 20:39

Yeah.

Thomas Chacko, MD: 20:40

so one, you just have to be aware there's consequences

Amanda Whitehouse, PhD: 20:43

Yeah,

Thomas Chacko, MD: 20:43

might be negative if you do wait.

Amanda Whitehouse, PhD: 20:46

You mentioned people talking about Xolair and throwing that into the equation and I know lots of people have different opinions, but I want you to share your take 'cause I think some people will find it very helpful.

Thomas Chacko, MD: 20:57

So I think Xolair is a tool that we have out there that, that may be helpful. Um. I think it's not needed in the majority of people that will go through OIT. We've been to OIT for a decade before we had Xolair. If you're on OIT and having issues, then Xolair might be a, uh, uh, an option. But remember again, 95% say I'm fine. And that 5% maybe. Um, so that's where I would say it. Um, I think there's a lot of promotion behind it, right? Because, because, um, there's a lot of marketing behind it and a lot of, uh, funding like multimillions behind it versus, versus just giving peanut flour, which costs nothing. So, so I think there, you have to be careful about who's giving the message and where that message is coming from. I don't think it's wrong, but do I think it's needed In the vast majority of patients, no. No, and the very important thing to know is Xolair is not disease modifying. That's the bigger thing, right? And just also figure out the logistics of doing it right? It's giving an injection a shot once or twice a month to a kid that costs 30,000 a year, which once you stop that shot doesn't change anything. You're back to square one. Where, where the other thing is just giving a Bamba puff. And allowing your body to really change your immune system long term. Uh, but there's no money behind the Bamba puff and you can hear a lot of money. So it, it is what it is. Uh, um, I, I'm not against people doing it, but everyone has to know the background behind it sometimes. Some of the messages

Amanda Whitehouse, PhD: 22:25

Yeah. Thank you for sharing that. I think it's really good to keep having conversations. That's why I'm doing this whole series of episodes because I think as allergy parents, we can feel, and a lot of the people I work with are overwhelmed, you know, they used to just be in despair because there's nothing we can do. We just avoid it forever. And now they're overwhelmed with decisions and the pressure of making, like I said, the right decision when there's so many more options out there. Right.

Thomas Chacko, MD: 22:49

Yeah, and, and I, and I wanna talk, they talk about, and you may be familiar with, with this matter, the, the OUTMATCH trial, that's the big Xolair trial that everyone talks about. And, and I, and I, I did a post on it, but I wanted you basically what It shows that if you give people Xolair, does help people to protect from accident. I think that makes sense. The bigger thing is. They want to take it a step further and say, Hey, if we give them Xolair and we give them OIT, will that help? And the take home was, it didn't work that well, but I, I think the devil's in the detail. The problem was they got people who were super allergic, super, super allergic and try in two months, tried to get them up, like someone who couldn't even take a, a little peanut to eight or nine peanuts and everyone dropped out. why, because they were like, we so, so everyone that was in the Xolair trial dropped out and then, so it made it look bad. But in reality, if you looked at the people who stayed in the study on the Xolair or um, on the OIT, they both wound up getting to the same point. My, my takeaway with that is it wound up being a negative study, like didn't look good. That helped with OIT because they went too fast. I actually think Xolair will actually help people with OIT. It's just a study was a little too aggressive to get there. Does that make

Amanda Whitehouse, PhD: 24:01

It does, and I appreciate you explaining that because that's another thing that parents get overwhelmed with research and trying to make sense of, you know, what the data behind things. It's, it's, it's helpful to have it explained in, in layman's terms like that for listeners. Thank you.

Thomas Chacko, MD: 24:15

So I hope that helps because we're gonna hear a lot about that.

Amanda Whitehouse, PhD: 24:17

Yeah. Is there more you wanna say on that before I move on?

Thomas Chacko, MD: 24:20

No, I think it actually gave, I think the goal of it was to, they know they can't be put people on Xolair indefinitely. The goal was that Xolair would help with OIT. It didn't show that, but I think it's because of the design study. I actually think it, think it would help actually if they just went a little slower.

Amanda Whitehouse, PhD: 24:35

Okay. Yeah. Well, and choices. And options. Right. You're talking about how you see things changing and evolving. So tell me more about what you see in the next 5, 10, 15 years with immunotherapy.

Thomas Chacko, MD: 24:46

Well, I think more data is gonna be on doing it lower and slower. Like meaning there's gonna probably be a sublingual one, a drop one coming out there. I know, uh, Edwin Kim's doing some data on that with both peanuts and likely tree nuts. That's probably gonna come out, where you basically give it under the tongue. Um, but at the end to, in my opinion, and I think the data which you'll is just given low dose oral immunotherapy, and, and you'll get there.

Amanda Whitehouse, PhD: 25:10

Is that different from slit? I'm

Thomas Chacko, MD: 25:12

SLIT

Amanda Whitehouse, PhD: 25:13

Okay. Okay, so do you mean it's gonna be more widely available or do you think there's gonna be a commercial version?

Thomas Chacko, MD: 25:19

There's gotta be commercial.

Amanda Whitehouse, PhD: 25:21

Because people can't, you know, obviously in private practice doctors are already doing slit for foods.

Thomas Chacko, MD: 25:26

Yes, yes. So just like there's a commercial version of Peanut Powder with Palforzia, there's gonna be a commercial version for SLIT coming out, most likely

Amanda Whitehouse, PhD: 25:35

Yeah.

Thomas Chacko, MD: 25:36

for Peanut and tree nut. And it's not any different than people are doing now, but it'll be, it'll, it'll most likely come out.

Amanda Whitehouse, PhD: 25:43

Yeah. Okay. What about the availability of OIT? I mean, right now it's, it can still be hard to find a doctor who offers it.

Thomas Chacko, MD: 25:51

So it's interesting, I think the Outmatch study will is gonna change the availability. And I don't know this, this is an opinion because, but this is my opinion. So I think what if that study would've been shown as a positive that Xolair helps people then to get OIT then more institutions would then introduce doing OIT with Xolair ahead of it. And, but because it didn't, they're just gonna be like, we're not gonna do OIT, we're just gonna do Xolair. I think in the US the dynamics of the us uh. Behind the pharmaceutical backing and also the sponsorship of many, many of our leaders who speak, um, um, make it very hard for OIT to be uptake in, in, in, in mainstream. That's why like in Canada, they do it all the time. In other countries they do it all the time. In the US uh, I think that a lot of pharmaceutical backing that will make it difficult to be taken up mainstream, right. No, like I've asked my academy and my college, can I speak? They're like, we only want FDA approved products somewhat.

And so how do you get FDA approved product? You need multi-millions to, to support it. And then you get the FDA approved product of slit or, or uh, a peanut where we already have those. It's just that once they want an FDA, a approved, it's just like Palforzia. It's just another cycle. So that's a long answer, Amanda. I don't think it's ever gonna come up in the US main

Amanda Whitehouse, PhD: 27:11

That's, I'm just kinda sitting here soaking it in because obviously I'm hopeful, so that's not necessarily what I was expecting you to say. Even though I have heard, like this is another common thing that people's doctors will tell'em, well, it's not FDA approved, but you can't get FDA approval for peanut flour. It's not a medication. But people like that pillow, that cushion. Yes.

Thomas Chacko, MD: 27:31

Yes. And, and a lot of people will say, Hey, we're waiting for studies to come out, but no one's funding those

No one's gonna fund a study that has, uh, or a very big study that gets published, uh, widely that's just natural foods. So it's very difficult to do that. I do wanna mention a study that was published in the New England Journal, which was excellent. I was shocked actually. I mean, in a great way. And basically what they did was they took elementary age kids, remember we were talking about starting young, but they took like. age kids um, but their peanut ID wasn't super high yet. It was okay. It was, and they gave them peanut butter. They just did OIT and it was. In New England Journal and they found out you do it elementary school and then they do it for like, let's say a year. Um, they're able to eat it freely or, or with peanut butter at, at like at high doses. So I love that study'cause it just showed natural foods. remember I said you gotta get on the infants, but they did show you get, you start'em in first grade, second grade you could even get them eating peanut butter jelly by the time they're in high school. So I, I thought that was an awesome study using just natural foods.

Amanda Whitehouse, PhD: 28:37

and I think it proves the point that you and I both know that just because something's not FDA approved doesn't mean there isn't any data to support its safety and its effectiveness. They're not equivalent.

Thomas Chacko, MD: 28:47

Agreed.

Amanda Whitehouse, PhD: 28:48

I, again, it's, it's, it's hard to sort through if you're not in the field, if you don't know research, if you don't know how this stuff works, right?

Thomas Chacko, MD: 28:55

I used to say it's like a secret society. You need to know someone that knows, and it still is because there's still, I think, the majority of people with, with food allergies in the US don't know about OIT as a, as an option. Like for example, if I went on, um, alright, we're gonna keep it honest, right? Like, like yeah.

Amanda Whitehouse, PhD: 29:18

I love it.

Thomas Chacko, MD: 29:19

If I went to speak on FARE and I said, hey, FARE, can I go do a speak on food? They won't let me talk. No.'cause who funds FARE? No way. No way. But wait, do we want all our food allergy patients to really know about their options, or do we only want them to know about the options that fund you? That's how it goes.

Amanda Whitehouse, PhD: 29:39

Yeah. Yep. And people don't know that. I'm learning so much about how all of this works behind the scenes because of the people that I've met through doing this podcast that, um, yeah, it's not as simple as it seems on the outside, and I appreciate your honesty because I think it's important for people to know.

Thomas Chacko, MD: 29:54

FARE, lemme know. I'd love to do a talk with

Amanda Whitehouse, PhD: 29:56

Yep. We can all come back and talk about it if they want to.

 A lot of people are hearing about TIP or the Tolerance induction program. What's your take?

Thomas Chacko, MD: 30:06

We've done some posts on our Instagram and we've actually had posts with other allergist commenting, so if you're interested in, I would, I would check our Instagram out because it also gives other allergist comments. And I think the biggest thing of that is I. Um, I'm not against it, but I think all it is just doing oral immunotherapy in a different way. I think that's all it is Slowly introduced, I would say they were ahead of the game. They've been doing it for a little while and very slow. Um, so I think that's, that part is good. Um, I think some of their methods are questionable, and I think they do a lot of, maybe some extra stuff, um, of which I'm not sure about. The question becomes, if you were my cousin, would I recommend you do it? Um, not, probably not for their price. And they, they're their not for their price point and uh, um, at that price or, or that inconvenience. I think there's probably allergists that could do very similar food introduction, right? You call it TIP, you call it oral immunotherapy. These are all just ways of food introduction, um, slowly getting the body tolerated. They do it one way. Other allergists do a different way, but, but, um, so I'm not against what they do. I think there's just different ways of getting to the same end point.

Amanda Whitehouse, PhD: 31:14

That's important to know. And I think, yeah, there's a significant cost and there's a lot of travel involved. You know, I remember reading about it when we were making decisions and it just wasn't, it was not an option for us, but I can see why people are drawn to it. Be. Because the way it's described, I think the discussion around it is a little bit different than the way we talk about OIT,

Thomas Chacko, MD: 31:31

Yes, and and, and I think their marketing is brilliant. Brilliant, brilliant. Uh, um, I have some questions because I've, you know, um, they say there's a hundred percent success rate or something like that, and nothing in medicine is a hundred

Amanda Whitehouse, PhD: 31:43

right?

Thomas Chacko, MD: 31:45

So to say that is to me is, is it's, it's difficult and I think they are, they argue that they're the only ones that allow free eating, which is also inaccurate. Meaning we have hundreds of patients across a hundred doctors across country. So I think those statements are bold

Amanda Whitehouse, PhD: 31:59

Yeah.

Thomas Chacko, MD: 32:00

I, and so, so that's my concern. I'm not against it, I'm just like. Man, keep it real. And that part is bothering me. Uh, um, but I, I don't think, I, I don't question their outcomes, meaning it makes sense to me. They just do it a different way, a hundred different things. So I would actually, if you were, if for advice for a patient, if you are considering TIP, would recommend at least getting a second opinion from an allergist that offers oral immunotherapy and just, and you make the decision yourself once you hear both sides.

Amanda Whitehouse, PhD: 32:27

Yeah, I agree. And I do like to always throw into that conversation. You know, I, I can attest to it. My son got to free eating for peanuts and cashews and pistachios with OIT. I can attest that it's true that people can get to, to free eating on OIT and a lot of the people I work with, I'd love to hear if you see the same thing. They don't want to, they, they don't want to eat it all the time. They just wanna be safer.

Thomas Chacko, MD: 32:47

Yep. I would say the majority of people, middle school and above have no desire to free eat it. No desire. And that's my, my, my gripe with Xolair, meaning they're like, oh yeah, you could eat eight

Amanda Whitehouse, PhD: 32:58

Mm-hmm.

Thomas Chacko, MD: 32:59

$30,000 and potato, like, no one cares about that. Literal no one, uh, or I shouldn't say, there's, never say never, but maybe 1%. They just wanna be protect from accidents. And you could do that with low dose OIT. You could do that with one Bamba. Yeah. It's very easy to get that, even those super high IGE there, it's, it's not that

Amanda Whitehouse, PhD: 33:15

Yeah,

Thomas Chacko, MD: 33:15

Yeah.

Amanda Whitehouse, PhD: 33:15

yeah, yeah. Thank you for all of your honesty. I love it. This is so helpful because this is, you know what I was saying earlier, this is why I think so many people trust you and are following what you're saying, because I think you just telling it like it is and you're not necessarily giving the coded answers, you're just saying the truth, and I think people really wanna hear it.

Thomas Chacko, MD: 33:32

I, I, I try to be honest, I, I take, if you see it, I, I take no sponsorships. People ask me to do

virtuals. I said no. You know, because, because I just see patients and we're really good at it. Uh, I, I have three or four docs who all came to me from academic food allergy centers that work with me. All of them have been in big academic institutions with food allergy centers and one was an attending, so I think we see a lot and I just, I like what I do. I don't care to be sponsored and just, I'll just talk to you like you were my cousin every time.

Amanda Whitehouse, PhD: 34:02

I love it. That's awesome. What am I missing? What else do you get tons of questions about? What other things do people really need to know?

Thomas Chacko, MD: 34:10

People ask me a lot about this egg ladder. They're like, what do you think about ladders versus OIT? Egg and milk. Like chew because you guys are your, your son is peanut tree. So that's not something that

Amanda Whitehouse, PhD: 34:18

No. No. Luckily we didn't have egg or, yeah, milk.

Thomas Chacko, MD: 34:21

So, um, what comes up? They, they ask me about that. Like, what do you think? Because that's done a lot in other countries and they're like, Hey, where do you think that helps? Like doing the egg and milk ladder, should we do that versus oral immunotherapy? Um, and um, it's, I would say I, we used to think that those ladders would help. Like, hey, giving in the bay form will help you to then develop tolerance to milk. Giving in the bay form to egg will help you to develop tolerance to egg over the past. Four or five years, we found out that they're a different phenotype or a different type of patient, and we realized that maybe that baked egg, the baked milk, it's okay, but it's probably not gonna let you eat the milk freely or eat the egg freely. And so I am not, in general, if someone comes to me with milk allergy and they can't eat the baked egg or they can't eat the milk, I'll just lean towards OIT. With egg, I might go, if they're eating baked, I'm like, eh, that's one of those maybes. But generally, I don't think now in Europe and, and Dr. Gideon Lack. At some point they might say, the ladders do work, but at least here. At least the data that we're seeing. Um, the ladders help, but they're not OIT, they're probably not gonna be, uh, it's a different type of patient. And so I likely lean towards OIT. It's one of those.

Amanda Whitehouse, PhD: 35:38

I, I love, I'm so glad you're mentioning this, and just for people who don't understand, what, what do you mean by phenotypes? Different phenotypes within those allergies?

Thomas Chacko, MD: 35:45

Phenotypes types is just like, um, the way your body's going to be, I guess, and there's some people, your body is what is, your genes are what they are. And so the question is. If you're the phenotype that is gonna be allergic to milk, if we give you the baked milk, will you then later be able to drink milk? And I would say probably not. That's your phenotype. The baked milk won't help that phenotype. And you need to go probably do oral immunotherapy. So. So phenotypes a fancy way of saying the way your body is, that's the group you're at.

Amanda Whitehouse, PhD: 36:16

Yeah, not, not anything about what we're giving you or anything you're doing wrong, just the physiological difference between your allergy and someone else's allergy.

Thomas Chacko, MD: 36:23

And, and, and we're talking about food allergies, but we're talk about food for the al allergy world. We talk about phenotypes and asthma because that's a lot of ones'cause certain phenotypes respond to certain medications. So that's just the way their body is and they respond this way. Same thing in food allergies. It might be pheno phenotypes and you respond in this way. It just depends.

Amanda Whitehouse, PhD: 36:42

Okay. Thank you for explaining all of that too. It's complicated, but

Thomas Chacko, MD: 36:46

Complicated, but it's,

Amanda Whitehouse, PhD: 36:48

it's good to know. It's, it's something else that should be in this conversation, right.

Thomas Chacko, MD: 36:52

Yeah, as you should know, because I get the question, Hey, my 3-year-old has milk allergy. If we do the baked ladder, do you think that will help me to outgrow it, and I'd say probably not. Most kids outgrow milk Anyway, trend your numbers, see which way you're going. If you look like you're in, the 80% is gonna outgrow it. You good. If you don't look like you're in the 80%, that's gonna outgrow it. Let's talk about OIT.

Amanda Whitehouse, PhD: 37:15

I have one more question for you. In my work, obviously supporting families through this, I often see in both directions a big difference between how parents are feeling about taking on an OIT and how the kids are feeling, both where the parents want to and the kids don't want to. And the opposite.

Thomas Chacko, MD: 37:31

Brilliant

Amanda Whitehouse, PhD: 37:31

What do you see?

Thomas Chacko, MD: 37:32

Brilliant. First of all, brilliant question.

Amanda Whitehouse, PhD: 37:35

I talk about it all day too.

Thomas Chacko, MD: 37:38

I've had seen where, where? Uh, Mary's going to college, or they're seniors and we wanna do something right before they go, and they're like, what do we do that child we want? And I've done this now 10, 15 years. And I'm like, look, they're 17. And the kid don't care. The kid's sitting there on their phone like chilling. But I'm just here'cause mom got me here. The kid has knowing. She's not worried about mom is so nervous that they're going away to college for their first time. My baby's going away. And what do we do?

and so they wanna do some treatment and, and it's not hard for me to do. I could do that very easily, but at that point I talk with mom, I'm like, they're 17. They're making their medical decisions next year. If it doesn't bother them the minute they leave at 18, just not gonna do the treatment. And they're not wrong, not doing the treatment. If you're worried about a reaction from food allergy when they go to college, remember there are a lot of other things. The drive to college is more worrisome, so I try to put that in perspective and I'm like, your kid, if it bothers them, we could do a treatment. But if we're doing it from mom and not the kid, and the kid doesn't have anxiety, I'm like.

And then I talk about my daughter. My daughter's a uh, a senior in high school and she'll be going away to college and I'm like, if she had food allergies and she had peanut allergy and she's not anxious and she lives her best life, would I do treatment? No, it's not needed. It's probably, there's other things I know we worry about a lot. There's other things, and the kid is also making the decisions at 18 anyway, so I'm telling more. More rising seniors not to do treatment than do treatment. And mom is like, okay. And now if the kid's nervous, different story, I'll, but I'll tell mom, look. And then I always say when you, Amanda, you ask, what do I do? If they were me? I always try to relate it to my kids and I'm like, if it was my kid, this is what I would do. Typically parents are pretty good when you're like, the doctor says this is what they would do with their kid. And so, uh, um, that's usually how I say it.

Amanda Whitehouse, PhD: 39:29

Yeah, I think that is such a good point in terms of wrong reasons to do OIT, right? Not if it's the right or wrong decision, but that is the wrong because all of a sudden mom is having a panic attack, you know, that is the wrong reason to all of a sudden push the kid into it and, and, and, and choose something last minute and rush and stress about it.

Thomas Chacko, MD: 39:47

Yeah. And, and then the kid will not do it when they, when they're outta the house.

Amanda Whitehouse, PhD: 39:50

Right.

Thomas Chacko, MD: 39:51

I, I've had very few college kids do oral immunotherapy when their parents were the driving, driving the shift.

Amanda Whitehouse, PhD: 39:58

Well, and I've seen that you probably have too, even with younger kids who are really resistant. And I'm not saying it's the wrong decision to do it, but if the child is not on board, I have worked with so many kids who were so far into OIT and then the parents found, you know, a garbage can full of three weeks worth of peanut M&M doses that the kid just refused to, you know, to take. And now obviously the doctor's working to get them back on and it's so much unnecessary stress. Again, not that the kiddos shouldn't do it, but to get them on board with it I think is so important.

Thomas Chacko, MD: 40:27

Uh, agreed. They have to be on board and remember, avoidance is still okay. You know, avoidance is still okay. My best friends, their kids, cashew allergic, they just avoid ca Actually, many of our friends that, uh, um, who are cashew allergic, uh, peanut allergic, they just avoid and they're okay. So avoidance is still okay. These are just options out there.

Amanda Whitehouse, PhD: 40:47

That is a perfect point and I, I will leave it at that unless you have final thoughts or anything you wanna add, because I think you said it very well.

Thomas Chacko, MD: 40:55

No, I think just, I think everything is individually based. Know your options, know what's out there. Babies lean towards treating that. I would say that. Um, but once you're older. And, um, just know avoidance is okay. Oral immunotherapy is okay. Uh uh, um, so many Xolair is okay, but just know just different options and let's have some discussions.

Amanda Whitehouse, PhD: 41:18

Perfect. Well, thank you for being such a big part of those discussions. I appreciate it and I know that everybody listening too will just love your take on it.

Thomas Chacko, MD: 41:24

This is, this is so much fun.

41:32

This season is about informed, thoughtful decision making, and I love all of that information that Dr. Chacko shared to help us clarify and challenge some of our assumptions. So here are your next three steps to follow up.

Number one. Follow Dr. Tom Chacko. I forgot to have him tell you himself where you can find him online and on his socials, but I will put them in the show notes. If you are local to the Atlanta area or able to travel to him, you can find his website at atlantaallergydoctor.com. Or you can just Google Chacko Allergy. His last name is spelled C-H-A-C-K-O. And even if you're not in the area, you can benefit from all of the conversations that he's having online, showing the great results that he's getting with his patients. And his Instagram account is @Chacko_Allergy.

Number two, if you are interested in exploring treatment options but aren't local to Atlanta, visit fastoit.org to find a list of providers who offer OIT where you might be able to access it. Even if it's just for a second opinion, or to explore options, knowing your choices matters.

And number three, if you're feeling emotionally overwhelmed by the decisions or how to navigate them once you make them, I wrote a workbook for you called From Fear to Freedom: A Guide to Navigating Allergy Immunotherapy. You can find it anywhere you buy books, but if you're considering it, I would encourage you to support your local bookstore by ordering through them or through bookshop.org. And of course, I'll put a link to that in the show notes as well.

Thank you again to Dr. Chacko for your honesty and your straightforward answers, and to all of you who are here listening and joining in these conversations with us. Please keep sharing the show, leaving your ratings and reviews so that more people can find this information and get the support they need. I'll be back next week.

The content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse. Thanks for joining me. And until we chat again, remember: don't feed the fear.