Sublingual Immunotherapy (SLIT) - General Information

Background on Sublingual Immunotherapy (SLIT)

The substances that trigger a patient's allergies are called allergens. Immunotherapy is a treatment of small amounts of allergens which are delivered by injection (needle) or sublingually (under the tongue via allergy drops) to alter the patient's immunity. The goal is to develop tolerance to the allergens that cause your symptoms. The allergens used for allergy drops are the same as those used for injections. The FDA has specifically approved the allergens for injection use. Using them for SLIT is considered an “off-label” use. Off-label use in the US healthcare delivery system is a legitimate, legal and common practice. The protocol we follow has been used in the United States for over 35 years and is endorsed by the American Academy of Otolaryngic Allergy (AAOA). SLIT has been used in Europe for over 60 years.

Purpose

The purpose of sublingual immunotherapy (allergy drops) is to decrease your sensitivity to allergy causing substances, so that exposure to the offending allergen (pollen, mold, mites, animal dander, etc.) will result in fewer and less severe symptoms. This does not mean that immunotherapy is a substitute for avoidance of known allergens or for the use of allergy medications, but rather is a supplement to those treatment measures. Allergy drops have been shown to alter your immune system's response to naturally occurring allergens. These alterations may permit you to tolerate exposure to the allergen with fewer symptoms. You, in effect, become "immune" or de-sensitized to the allergen. The amount of this immunization is different for each person and is, therefore somewhat unpredictable. Improvement in your symptoms will not be immediate. It usually requires 3-6 months before any relief of allergy symptoms is noted. About 85-90% of allergic patients on immunotherapy note significant improvement of their symptoms. This means that symptoms are reduced, although not always completely eliminated.

Procedure

Allergy drops are usually begun at a very low dose. This dose is gradually increased on a regular basis until a therapeutic dose (often called the "maintenance dose") is reached. The maintenance dose will differ from person to person. Drops are administered at home daily. The first dose of every bottle will be administered in our office. Drops are placed under the tongue, held for two minutes, and then swallowed. They taste slightly sweet and are not unpleasant. No refrigeration is required.

Duration of treatment

It usually takes several months to reach maintenance dose. The time may be longer if there are reactions or if the drops are not administered on a regular basis. For this reason, it is important that the recommended schedule be followed. If you anticipate that regular use of the drops cannot be maintained, immunotherapy should not be started. Immunotherapy may be discontinued at the discretion of your doctor. Most immunotherapy patients continue treatment for 3-5 years.

Adverse Reactions

Dozens of research studies show that allergy drops are a safe, effective form of immunotherapy. Local reactions for SLIT are uncommon and are usually restricted to mouth itching or stomach upset. Membranes under the tongue have fewer anti-inflammatory cells than the skin making reactions far less likely. Dendritic cells under the tongue move the drops to lymphoid tissue and then the immune response occurs. This process eventually creates allergen tolerance. Any mild reactions are more likely to occur at the very beginning of treatment or as you reach the higher concentrations of antigens in your drops. The reactions usually occur immediately after taking a dose, but can occur hours after. Most of the time these reactions resolve themselves, or with simple dose adjustments. If needed, an antihistamine can be used as normally directed. As with the case of any type of immunotherapy, a severe allergic reactions known as anaphylaxis can occur. Immunotherapy patients are required to always have an emergency auto-injector of epinephrine available. (Epi-Pen or Auvi-Q) Reactions are unpredictable and may occur with the first sublingual dose administrated or after a longer time of taking the drops, with no previous warning. All generalized reactions require immediate evaluation and medical intervention. If a localized or generalized reaction occurs, the dosage of the drops may be adjusted for subsequent treatment. Please notify our office of any reactions.

Missed Doses and Resuming Treatment

If more than one day of doses is missed, do not try and "catch up" by taking more than the daily prescribed dose. Call the allergy office for instrucitons.

Pregnancy and Nursing

Females of child-bearing potential: If you become pregnant while on immunotherapy, notify the office staff immediately, so that your doctor can determine an appropriate dosage schedule for the drops during pregnancy. Immunotherapy doses will not be advanced during pregnancy or while nursing, but may be maintained at a constant level if approved by your OB physician.

New Medications

Please notify the office staff immediately if you start any new prescription medication, particularly Beta Blocker medication for high blood pressure, heart problems, migraine headaches, and glaucoma. Beta Blocker medications are not to be used while on immunotherapy. Your drops will have to be discontinued.

SLIT Fact Sheet - Drops vs Injections

Oral Drops

Injections


Taken daily for 3-5 years

Taken weekly for 1-2 years then every 2-3 weeks for a total of 3-5 years.


Drops taken at home. Only the first dose of each new bottle must be taken at our office. (Every 21 days during the 4 bottle build up.)

Injections administered in physician's office or acceptable medical facility.


No time away from work or school except when beginning a new vial. A 20 minute wait is required after these visits.

Time to get injections plus a 20 minute wait after receiving injections.


Treatment not affected by travel.

Treatment not usually available while traveling.


No needles or apprehension.

Small needles used for injections.


Small chance of reactions.

Small chance of reactions.


Maintenance dose typically achieved in 84 days. May have fewer allergy related symptoms in 2-3 months.

Maintenance dose achieved in 1-2 years. May have fewer allergy related symptoms in 6-8 months.


Not covered by insurance. Methods of payment are cash, credit card or check.

Partially or completely covered by most insurance after deductible is met (if applicable.)


Extracts are FDA approved but delivery method is not approved. Insurance will not cover and cannot be billed due to delivery method.

Extract and delivery method are approved by FDA


Patient responsible for correct dose and staying on daily schedule.

Patient responsible for staying on schedule but nurse responsible for correct dose.


Patient required to have emergency epinephrine (Epi-Pen or Auvi-Q) on hand when drops are taken.

Patient required to bring and show emergency epinephrine (Epi-Pen or Auvi-Q) at each injection.

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