When the nearest clinic is not reachable

On the FAST OIT directory — the largest public list — clinics are listed across 35 states. The states with no listing are Arkansas, Delaware, Hawaii, Kentucky, Maine, Montana, Nebraska, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia and Wyoming, plus the District of Columbia. One important caveat: the directory is self-registered and not vetted, listings auto-renew yearly, and a clinic that never signed up will not appear. Absence from the list is not proof that no clinic exists in your state — it is a reason to call and ask rather than to assume.

The best current US figure comes from a 2026 study of allergist access across the 12 Midwest states, covering 379 practice locations: a median distance of 57.3 miles to the nearest allergist, with an interquartile range of 30.1 to 109.8 miles. Two honest caveats. That is distance to any allergist, not to one offering oral immunotherapy, which is a much smaller group. And the authors measured from county centroids, which they note treats everyone in a county as a single point — so it does not capture how far any particular person lives from care.

Both matter, but travel is measurable and under-discussed. In a study of 67 patients on the waiting list for commercial peanut oral immunotherapy, 52% declined the therapy. The leading reason, at 28.5%, was time burden — defined by the authors as including travel distance to clinic, the number of clinic visits during up-dosing, and the treatment being lifelong. Lifestyle modification was second at 25%. These were patients who had already been offered the treatment, so the barrier was not awareness or eligibility.

It narrows it. Palforzia was the standardised, FDA-approved route, which meant a general allergist could in principle prescribe it rather than referring to a specialist OIT centre. It was withdrawn from the US market on 31 July 2026. Peanut oral immunotherapy continues, but now entirely off-label at centres that build their own protocols — a smaller set of providers, more concentrated geographically.

Three, in the order worth trying. First, ask your local allergist directly whether they offer oral immunotherapy — the directories are incomplete and many practices do not list themselves. Second, discuss Xolair, which is FDA-approved to reduce the severity of reactions to accidental exposure; it is an injection every two to four weeks and may be administrable closer to home. Third, consider sublingual immunotherapy, which is taken at home and can be supervised remotely, with the honest caveat that it raises reaction thresholds less than oral immunotherapy does.

Anyone with a history of anaphylaxis needs careful in-person assessment before starting any immunotherapy. Anyone with severe or poorly controlled asthma alongside a food allergy should be managed in person, because asthma control materially changes the risk profile. Food challenges and oral immunotherapy build-up require in-clinic supervision on every protocol — those are not home procedures, and no remote service should offer them. If travel is the obstacle, that is a real problem to solve, not a reason to accept a less safe version of a supervised procedure.