Traditional Immunotherapy vs. Immunotherapy Drops or SubLingual ImmunoTherapy (SLIT)

Traditional Immunotherapy vs. Immunotherapy Drops or SubLingual ImmunoTherapy (SLIT)

Introduction

Allergic rhinitis or “hay fever” usually lasts 10-20 years in most patients. Medicines do not cure the problem, and it is not always possible to avoid the cause (such as grass or ragweed pollen). Desensitisation (immunotherapy) is currently the only way of “teaching” the immune system to tolerate allergic triggers. It is effective in most people with hay fever and often helps those with asthma. Unfortunately, it has not definitely been shown to help people with eczema, and there is no evidence that food allergy can be controlled in this way, although research is ongoing.

How the treatment works

Our immune system responds to substances in our environment that we eat, drink or inhale, but only allergic people develop an “allergic” immune response. By giving small but increasing amounts of allergen at regular intervals either by injection or orally, tolerance to inhaled allergen increases. On re-exposure to allergen, symptoms may be milder or not occur at all.

How can this be done?

Injected immunotherapy has been given by injection for more than 60 years and many studies prove that it is effective. A number of studies published in the last 5 years have shown that very high dose sublingual immunotherapy (SLIT), where several drops of the allergen extract are retained under the tongue for a few minutes, then swallowed, can also be effective. This form of treatment has a history of use in Europe where it is used more commonly than injected immunotherapy. The glycerinated allergen extracts currently FDA approved for injections in the United States are the same extracts used for SLIT in Europe. It is important to note that these extracts are very potent, and NOT the extremely weak and ineffective extracts used by some medical practitioners for sublingual therapy 10 or more years ago.

Who should have immunotherapy?

Immunotherapy is indicated in people when:

• Allergy is severe, or

• The cause is hard to avoid, or

• Reducing exposure to allergenic triggers is only partially effective, or

• Medication does not work, or

• Medications cause side-effects, or

• A person would prefer to avoid medication.

How well does sublingual immunotherapy work?

Injected immunotherapy has been in use for over 60 years, and about 3 in 4 patients with hay fever experience significant improvement with immunotherapy. Sublingual immunotherapy (SLIT), where the allergen extracts are taken by mouth, has a much shorter history of use, but a number of studies published in the last 5 years show evidence of effectiveness. It is difficult to advise exactly HOW effective this form of treatment may be until more experience is obtained in the United States. In particular, it is unclear whether it will be as effective as immunotherapy given by injection. Sometimes symptoms are reduced rather than abolished. When immunotherapy is only partially effective, you may need medication as well.

Why chose sublingual (SLIT) instead of injected immunotherapy?

The potential advantages of sublingual treatment are those of:

• No injections

• Fewer regular doctor visits

• No waiting periods after the injections

• A lower likelihood of side-effects

The main disadvantage of SLIT is cost; much more allergen needs to be swallowed than injected, resulting higher cost for extract. Some people also dislike the taste. On the other hand, this needs to be balanced with the time, cost and convenience in having fewer doctor visits, and being able to administer the antigen without comming into the office. In practice, those more likely to chose SLIT will be those who hate needles, people who don’t have time to wait in doctors rooms after injections, people who travel often and parents of young children, who may not wish for their child to have lots of injections. On the other hand, in an adult presenting with allergic disease where immunotherapy is appropriate, injectable immunotherapy is much more likely to be recommended in the United States at this time, because of greater published evidence of effectiveness, and more experience with this form of treatment.

How long does it take for immunotherapy to work?

Improvement does not occur immediately with either form of immunotherapy. Both usually require at least 4-5 months before hay fever symptoms improve, sometimes longer. If you are having treatment because of Spring / Summer hay fever, you usually know quite clearly in the first season.

Can you still use medicines as well?

Yes. You can still use your usual allergy medicines while doing either form of immunotherapy.

Common methods for taking immunotherapy drops (SLIT)

• Take in the morning on an empty stomach

• Keep them under the tongue for at least 2 minutes, then swallow.

• Do NOT eat anything for 15 minutes.
• Avoid crunchy cereals as these may cut the tongue and increase
the likelihood of mouth irritation from the extracts

• If you forget to take them in the morning, take them before bedtime instead

How long does immunotherapy treatment go on for?

Immunotherapy is not a “quick fix”. You need to be committed for it to work, and to cooperate with you doctor to reduce the risk of side-effects. If you find it helps in the first year, evidence is that patients continuing SLIT continue to improve even more in their second year of treatment. The minimum recommended duration for either form of immunotherapy is 3 years (5 years is better) to reduce the chance of your allergy returning once you stop treatment.

Risks and side-effects of SLIT:

COMMON

Salty or medicine taste - extracts do contain phenol as a preservative and may give the drops a medicine taste

UNCOMMON ~ 5 – 10 %

Irritation or itching inside the mouth - this can be controlled by temporarily reducing the dose or taking an antihistamine beforehand.

RARE ~ 3-5%

Stomach upset

IMPORTANT NOTE: It should be noted that dangerous side-effects such as difficulty breathing or rashes have been rarely reported with SLIT. That does not say it could never occur. One brand claims 100 million doses administered without a single case of serious allergic reactions at the time of writing (January 2008).

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