Four routes, four different jobs
An honest map of food allergy treatment — including where the option we provide is not the strongest one.
Palforzia is FDA-approved oral immunotherapy for peanut only. Xolair is FDA-approved to reduce the severity of reactions to accidental exposure — but it does not desensitize you. Clinic-based OIT covers more allergens off-label and raises reaction thresholds the most. Sublingual drops raise thresholds less, but cause far fewer reactions and fit an ordinary life more easily. None of them is best in the abstract.
Medically reviewed by Dr. Chet Tharpe, M.D. · Last reviewed August 2026
The landscape
What is actually approved
Two of the four routes carry FDA approval. That is the first thing worth knowing, and it is not the same as the first thing worth choosing.
- FDA-approved food allergy treatments
- 2FDA-approved food allergy treatments
- allergen covered by approved OIT — peanut
- 1allergen covered by approved OIT — peanut
- reaction threshold increase on OIT at 12 months
- 141×reaction threshold increase on OIT at 12 months
- reaction threshold increase on SLIT at 12 months
- 22×reaction threshold increase on SLIT at 12 months
Threshold figures come from a randomized head-to-head comparison in peanut-allergic children (PMID 25528358). Every route still requires an epinephrine auto-injector.
Side by side
The four routes
Palforzia
FDA-approved- Status
- FDA-approved 2020; extended to ages 1–3 in July 2024
- What it does
- Raises the peanut reaction threshold
- How it is taken
- Daily oral powder; build-up supervised in clinic
- Ages
- 1–17
Xolair (omalizumab)
FDA-approved- Status
- FDA-approved February 2024
- What it does
- Reduces reaction severity on accidental exposure — does not desensitize
- How it is taken
- Injection every 2–4 weeks
- Ages
- 1 and older
Clinic-based OIT
Off-label- Status
- Off-label for allergens other than peanut
- What it does
- Raises the reaction threshold — the largest effect of the four
- How it is taken
- Daily food or protein dose; build-up and challenges in clinic
- Ages
- Varies by centre
Sublingual immunotherapy (SLIT)
Off-labelWhat Curex provides- Status
- Off-label; compounded, not FDA-evaluated
- What it does
- Raises the reaction threshold — smaller effect than OIT
- How it is taken
- Daily drops under the tongue, at home
- Ages
- From 2 at Curex
The head-to-head
OIT is more effective. Drops are easier to finish.
Both halves of that sentence are supported, and leaving either one out would be misleading — including the half that does not favour us.
Stated plainly — this is the option we do not provide.
- Much larger threshold increaseIn a direct comparison in peanut-allergic children, oral immunotherapy produced roughly a 141-fold increase in reaction threshold at 12 months, against roughly 22-fold for sublingual.
- An FDA-approved product existsPalforzia is approved for peanut, ages 1–17. No sublingual food product has FDA approval; drops are compounded and off-label.
- Supervised build-upDoses are escalated under clinical observation, which is the safer way to handle the riskiest phase.
Sustainability, not potency.
- Markedly fewer adverse reactionsThe same head-to-head found OIT associated with significantly more adverse reactions and more early withdrawals.
- Fits an ordinary weekNo exercise restriction after a dose, dosing usually continues through a mild illness, a few missed days do not force a restart, and there is no fixed dosing time.
- Possible on-ramp to OITEmerging evidence suggests 1–2 years of sublingual dosing may be a safe way to bypass the riskiest phase of OIT build-up — sequential rather than rival.
The honest summary: a course that gets finished at a smaller effect size can beat a larger one abandoned in month four. That is the trade, and which side of it suits you depends on your family, not on which company you ask.
Unchanged by any of it
What every route requires
- An epinephrine auto-injector, on every route, throughout treatment.
- In-clinic supervision for food challenges and OIT build-up. These are not home procedures on any protocol.
- Careful assessment where there is a history of anaphylaxis before starting anything at all.
- In-person management where severe or poorly controlled asthma sits alongside the food allergy.
Access
If there is no food allergy clinic near you
The established oral immunotherapy centres are concentrated in a handful of metro areas, mostly in California and New York. For most of the country, reaching one means travel, time off, and repeat visits over years.
If that is not realistic, the honest options are to ask a local allergist whether they offer OIT, to discuss Xolair with them, or to consider sublingual immunotherapy, which can be supervised remotely. The option that is not defensible is assuming avoidance is the only thing left — see which parts of allergy care transfer to remote treatment.
❓Frequently Asked Questions
Two. Palforzia, an oral immunotherapy powder for peanut allergy, approved in 2020 for ages 4–17 and extended in July 2024 to ages 1–3. And Xolair (omalizumab), approved in February 2024 to reduce allergic reactions, including anaphylaxis, from accidental exposure in patients aged 1 and older with IgE-mediated food allergy. Everything else — including clinic-based oral immunotherapy for allergens other than peanut, and sublingual food drops — is prescribed off-label.
No, and this is the most commonly misunderstood point. Xolair reduces the severity of a reaction if you are accidentally exposed. It does not build tolerance to the food, and you still avoid the allergen while taking it. It is given by injection every two to four weeks. Immunotherapy — oral or sublingual — is the category that aims to change the underlying response.
Yes, on threshold. In a direct comparison in peanut-allergic children, oral immunotherapy produced roughly a 141-fold increase in the reaction threshold after 12 months, while sublingual immunotherapy produced roughly a 22-fold increase. Both are meaningful; OIT is substantially larger. The trade-off is that OIT was associated with significantly more adverse reactions and more people dropping out. Anyone claiming drops outperform OIT on effectiveness is misreading the evidence.
Because effectiveness on paper is not the only thing that decides whether a treatment works in a real family. Sublingual dosing has a markedly better safety profile, and it is easier to sustain: no exercise restrictions after a dose, dosing can usually continue through a mild illness, missing a few days does not force a restart, and the dose is not tied to a particular time of day. A course that gets completed at a smaller effect size can beat a larger one that gets abandoned in month four.
Not the first step, and not for everyone. Oral immunotherapy build-up and food challenges require in-clinic supervision because of the risk of a systemic reaction. Sublingual drops are taken at home, but candidacy still has to be assessed by a clinician, an epinephrine auto-injector is required, and a history of anaphylaxis calls for careful evaluation before starting anything. Anyone with severe or poorly controlled asthma alongside a food allergy should be managed in person.
That is the practical reality for most of the country — the established oral immunotherapy centres are concentrated in a handful of metro areas, mainly in California and New York. If travelling to one is not realistic, the honest options are to ask a local allergist whether they offer OIT, to discuss Xolair with them, or to consider sublingual immunotherapy, which can be supervised remotely. What is not a good option is doing nothing on the assumption that avoidance is the only alternative.
If you experience sudden difficulty breathing, throat swelling, or other signs of anaphylaxis, call 911. A prescribed epinephrine auto-injector is the first-line treatment — not antihistamines.
This content is for informational purposes only and does not constitute medical advice, diagnosis, or treatment. Always consult a qualified healthcare provider with questions about a medical condition. Content reviewed by board-certified allergists at Curex.
Sources: FDA approvals for Palforzia (2020, extended July 2024) and Xolair (February 2024); randomized comparison of sublingual versus oral immunotherapy for peanut allergy (PMID 25528358). Curex provides sublingual immunotherapy, one of the four routes described here.
Keep reading
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- How Curex worksThe treatment process end to end, from at-home testing to daily drops.Read
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- Evidence & guidelinesWhat the FDA approved, what the AAAAI/ACAAI practice parameter does and does not endorse, and what has been added since.Read
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