What food allergy treatments exist now that Palforzia is gone?

Three immunotherapy approaches are now available for food allergy: oral immunotherapy (OIT), sublingual immunotherapy (SLIT), and Xolair (omalizumab) — recently FDA-approved for food allergies. They differ significantly in evidence base, efficacy, safety profile, accessibility, and patient completion rates.

Oral immunotherapy involves ingesting gradually increasing amounts of the allergenic food, typically starting at microgram doses under medical supervision and escalating over months to a maintenance dose. The PALISADE trial (PMID: 30449234) demonstrated the strongest food allergy treatment data to date: 67.2% of treated children tolerated 600mg peanut protein at exit food challenge versus 4.0% placebo (p<0.001). Among completers, 85% tolerated 600mg and 50% tolerated 1,000mg.

However, OIT carries meaningful risks and a significant dropout problem. Systemic allergic reactions occurred in 14.2% of treated patients versus 3.2% placebo. Epinephrine use during treatment was 7.7% (active) versus 3.4% (placebo). All-cause dropout in PALISADE was approximately 21% (78/372), with 11.6% discontinuing specifically due to adverse events. Gastrointestinal side effects — abdominal pain, nausea, vomiting — are the primary driver of OIT dropout. Adult dropout was 51%. The meta-analytic estimate for eosinophilic esophagitis (EoE) risk is 2.7% (Lucendo et al. 2014, PMID: 25216976). Academic centers offering supervised food OIT include Stanford (Sean N. Parker Center), UNC Chapel Hill, Johns Hopkins, Mount Sinai, Duke, and Arkansas Children's.

Food SLIT delivers tiny allergen doses under the tongue rather than through ingestion. It is a fundamentally gentler approach: the allergen contacts the sublingual mucosa (rich in tolerogenic dendritic cells) without passing through the GI tract at therapeutic doses, which is why the gastrointestinal side effects that drive OIT dropout rarely occur with SLIT.

Food SLIT is not new. Allergy clinics have been using sublingual food allergen protocols since the 1990s. Allergychoices — the company behind the La Crosse Method Protocol, the most widely used SLIT protocol in the US — has treated over 50,000 patients with food allergies specifically, through a network of 2,000+ providers over more than 50 years. Because food allergies carry elevated risk compared to environmental allergies, many allergy providers choose not to offer food immunotherapy at all. The providers that do have developed safety protocols specifically for this higher-risk population.

Peanut is the best-studied food SLIT allergen, with six published clinical trials.

The PITS trial (Kim et al. 2024, PMID: 37815782) is particularly notable because it enrolled very young children (ages 1-4) and demonstrated 48% vs 0% three-month remission — with the strongest response in 1-2 year olds (75%). Food SLIT safety is dramatically better than OIT: systemic reactions are very rare (<0.5% of doses), no epinephrine has been required in any published peanut SLIT trial, and multisystem reactions are 11-fold less common than with OIT (Keet et al. 2012, PMID: 22130425). The practical consequence: patients are far more likely to complete a full SLIT course because they are not dealing with the GI distress that causes OIT dropout.

Curex launched its food allergy program in October 2024, offering sublingual immunotherapy for 90+ food allergens at $149/month — one of the only telehealth food SLIT providers operating nationwide. Because food allergies carry higher risk than environmental allergies, Curex has adapted its protocols specifically for home use. Patients are required to have an EpiPen on hand during treatment. The initiation and buildup phase uses a more gentle dose escalation schedule than typical in-clinic protocols, designed to minimize the already-low risk of systemic reactions in a home setting. Treatment plans are supervised by Curex's clinical team, with dose adjustments available via text, call, or video.

Nectar's NYC clinic also offers food SLIT, including peanut sublingual therapy, with the advantage of in-person supervision during initiation. Wyndly does not offer food allergy treatment. The broader context: most allergy providers — both traditional and telehealth — choose not to offer food immunotherapy because of the elevated risk profile. The providers that do accept this risk have invested in specific safety protocols.

In February 2024, the FDA approved Xolair (omalizumab) for food allergies in patients aged 1 and older — the first biologic approved for food allergy treatment. Xolair is an anti-IgE monoclonal antibody given by injection every 2-4 weeks. It does not desensitize patients to specific foods the way OIT or SLIT does. Instead, it raises the threshold for allergic reaction across multiple foods simultaneously, reducing the risk of severe reactions from accidental exposures.

The more promising development is emerging combination therapy: several academic centers — notably Stanford's Sean N. Parker Center and Mount Sinai's Jaffe Food Allergy Institute — are experimenting with Xolair injections combined with aggressive OIT or SLIT protocols. The rationale: Xolair suppresses IgE-mediated reactions during the highest-risk updosing phase, potentially allowing faster dose escalation with fewer side effects. This omalizumab-facilitated approach is still emerging and currently available only at select academic hospitals with specialized food allergy programs. It is not yet available through telehealth providers.

The clearest comparison comes from Narisety et al. 2015 (PMID: 25528358), the only randomized head-to-head trial of food SLIT versus OIT for peanut. OIT achieved 141-fold threshold increase versus SLIT's 22-fold — but with significantly more adverse events and higher dropout.

Regardless of whether a patient uses OIT or SLIT, treatment graduation requires an oral food challenge (OFC) — a supervised, in-person procedure performed at an allergist's office. During an OFC, the patient ingests gradually increasing amounts of the food allergen under medical observation, typically over 2-4 hours, with emergency equipment available. The OFC confirms whether desensitization has been achieved and determines the patient's current tolerance threshold. This step cannot be done at home. Patients using at-home SLIT through providers like Curex or Nectar will need to coordinate an in-person OFC with a local allergist to confirm treatment success.

Save your money and consider watchful waiting if your child's food allergy is likely to resolve naturally. Cow's milk allergy resolves in 79% of children by age 16 (Skripak et al. 2007, PMID: 17935766). Egg allergy resolves in 68% by age 16 (Savage et al. 2007, PMID: 18073126). Wheat allergy resolves in approximately 65% by age 12. Peanut and tree nut allergies are less likely to resolve (20-22% and 9-14% respectively), making them the strongest candidates for immunotherapy. Food SLIT evidence is still early-stage — peanut is the only well-studied allergen. If your child has severe anaphylaxis history and you pursue treatment, supervised OIT at a major academic center with emergency preparedness is safer than any at-home approach.