Do you still need an EpiPen after oral immunotherapy?

Oral immunotherapy (OIT) can change daily life for a child with a food allergy: a bite of peanut that once meant an ambulance can become a measured daily dose. So families ask the obvious next question: once treatment works, do you still need an EpiPen after oral immunotherapy? A national survey of Canadian allergists, presented at the Canadian Society of Allergy and Clinical Immunology (CSACI) meeting in Toronto in October 2026, found there's no standard answer yet. Most allergists decide case by case.

What OIT does, and doesn't, do

In OIT, a person eats a small, measured amount of the food they're allergic to, and the dose is raised step by step to a daily maintenance amount. Food Allergy Canada notes that the maintenance dose has to keep being eaten to stay desensitized, that OIT carries some risk, that not every child responds the same way, and that reactions can happen even at doses that were tolerated before, set off by things like exercise, infections or asthma flare-ups.

That's the key to the EpiPen question. OIT raises the amount of food it takes to cause a reaction, and the daily dose keeps it there. Only some patients reach "sustained unresponsiveness", staying protected even after a break from daily dosing.

Do you still need an EpiPen after oral immunotherapy? What allergists said

Researchers at Western University and the University of British Columbia surveyed Canadian allergists involved in food OIT through the CSACI membership list. 36 replied, about 18% of the country's allergists, most of them in community clinics in Ontario, British Columbia and Quebec.

Asked whether patients should keep carrying an epinephrine device after OIT:

• The most common answer was case by case.
• Next came continue for a set period, such as 6 to 12 months.
• Fewer said to stop once the patient has eaten the food at home without a reaction, or after passing a final food challenge in the clinic.
• The fewest said to continue indefinitely.

Other findings:

• What counts as success differs. 83% defined successful OIT as eating the food regularly without reactions, 73% as passing a final food challenge in the office, and 47% pointed to blood test trends.
• Only 16% routinely assess sustained unresponsiveness. The most common way to test it was a supervised food challenge in the office (48%).
• Follow-up varies: 47% see patients at set intervals after OIT, 33% as needed, and 20% have no routine follow-up.
• At follow-up, the top concerns were reactions coming back (81%), reassessing whether epinephrine is still needed (65%), co-factors and real-world exposures (62%), and whether to restart treatment (62%).
• 60% named limited time and resources as a major barrier to standard follow-up, and 81% said a national guideline would help.

Percentages are of the allergists who answered each question.

Low-dose peanut OIT: the 30 mg vs 300 mg trial

A second poster at the same meeting followed up a Canadian trial at McGill University and The Hospital for Sick Children that randomly assigned 51 peanut-allergic children (median age 10) to a daily maintenance dose of 30 mg or 300 mg of peanut protein, or to avoiding peanut.

• At one year, published in 2026 in The Journal of Allergy and Clinical Immunology: In Practice, 13 of 17 children on 30 mg and 10 of 17 on 300 mg could eat at least 443 mg of peanut protein in a food challenge, compared with none of the 17 avoiding peanut. The 30 mg group had fewer whole-body reactions.
• At 21 months, the new poster found blood markers behaved the same way on both doses: peanut-specific IgG4 kept rising while IgE changed little. Blood results were available for 14 of the 17 children on 30 mg and 9 of the 17 on 300 mg. The authors say this may support similar clinical results from the lower dose.

For families, a lower daily dose could mean a simpler routine with fewer reactions. It doesn't settle the epinephrine question: children on either dose were still in treatment.

Questions to ask your allergist

• Should we keep carrying epinephrine after OIT, and for how long?
• What do we do if we miss doses, or my child is sick or exercising hard?
• Will you test for sustained unresponsiveness, and how?
• How often will you see us after treatment, and what does "success" mean for my child?
• If OIT has been too hard, would sublingual immunotherapy suit us better?

Our take: keep it with you until your allergist says otherwise

Until your allergist tells you it's safe to stop, keep two doses of epinephrine with you, in date and in range, and keep your emergency plan current. The survey shows the decision is individual, so ask for it in writing for your child.

If you're still carrying, the Forget-Me-Not Epi Tracker can ping your phone if the kit gets left behind, on iPhone and on Android phones that support left-behind alerts. The ResQBand Tap Card gives whoever is with your child the steps to use it. More on keeping the kit with you in forgot your EpiPen?

Disclosure: ResQBand comes from Western Allergy, which has supplied allergy diagnostics and compounded immunotherapy prescriptions since 1972.

About the studies

Beyond OIT: What Happens After Desensitization? was presented by Sinthiha Krishnan, Stephanie Erdle, Tiffany Wong and Samira Jeimy of Western University and the University of British Columbia. The 21-month peanut results were presented by Diana Toscano-Rivero, Julia Upton, Moshe Ben-Shoshan and colleagues from the Research Institute of the McGill University Health Centre, the Montreal Children's Hospital and SickKids. Both were posters at the 81st CSACI Annual Scientific Meeting in Toronto, October 2026, and poster results are early findings.

This article summarises research for general information. It isn't medical advice: follow your allergist's plan. In an emergency, call 911.