Dr. Thompson,
Two questions:
Can SLIT also treat animal allergies, and if so would allergic animal owners be eligible for the treatment?
Also, you stated that SLIT will only treat one allergy, ie. dust mite, so is there no way to use multiple SLIT for different allergies, just as multiple injections are given in SCIT?
Katie,
Your comments and questions are appreciated. SLIT offers an alternative to allergy shots but has several shortcomings as discussed in the posting. SLIT has been done with both cat and dog allergen in Europe and in the United States (not FDA approved here). Published reports reflect better outcomes with cat desensitization. When SLIT becomes available pet extracts will likely be an option.
Few studies have shown effective desensitization to more than one unrelated allergen (for example grasses and trees, or ragweed, cat and dust mite). One problem is the increased volume of extract required to be placed under the tongue as more allergens are included. A second problem is the escalation of the cost when multiple allergens are involved. There are clinical trials being conducted to address these issues. As you mentioned, allergy shots (SCIT) offer multiple allergen desensitization.
Thanks again for sharing your thoughts,
J. Thompson, MD
I am in the U.S. and have been taking allergy drops (SLIT) for about 7 months now. There is a clinic in La Crosse, Wis. (Allergy Associates) that offers SLIT. Since it is not FDA approved, the drops are unfortunately often not covered by insurance.
I am pretty badly allergic to animal dander and I have a few other mild allergies. The drops I am using do contain multiple antigens. They seem to be helping me become gradually less allergic to cats. At my last appointment, my skin prick test showed I was less allergic than I was at my initial visit.
Hi Sara,
Sorry I missed your comment months ago. I wonder How you are coming along with your SLIT. I am glad you have responded well. When SLIT becomes FDA approved and more information is available on appropriate and safe doses, I will probably begin treating some of my patients with it as an alternative to shots.
Experts in allergy have estimated SLIT to be about 50% as effective as allergy shots given by a board certified allergist.
Good Luck!
J. Thompson, MD
I also have been on SLIT for seven and one half months. I tested positive for 28 out of 32 allergins. I also had chronic sinusitus from years of allergies that were uncontrolled, and my asthma was acting up from the sinusitus. Not only have my allergy sensitivities decreased and my asthma gotten better, but my sinsuses have slowly cleared out. I now feel air in places in my head I did not know existed. I only take 3 drops under my tongue in the AM and all 28 triggers are in the solution. I am very happy and willingly pay for the drops out of pocket (it would be nice if they were covered) for the benefits and convenience. My husband is on allergy shots and trying to get him to remember to go every two weeks for a shot is a problem. He often forgets which negates the effect.
Hi,
You appear to be another satisfied customer on SLIT. That's good. Those three drops under your tongue sure seem to cover an awful lot of trigger factors. Most well controlled studies on SLIT contain one or only a few allergens because amounts needed are much greater in volume than the quantity typically used in allergy shots.
No good clinical trials have shown favorable results in as high a number of allergens you are getting (I don't think such studies are available).
The important thing is it is working for you. SLIT will likely be approved in the U.S. in the near future. I plan on using it in some patients once approval has been achieved and dose schedules have been published.
Thanks for sharing,
J. Thompson, MD
Hi Lori,
I probably should have left "near" out of the sentence regarding when SLIT will be approved by the FDA. There are several issues that need to be worked out before approval. I don't know when this will be but support for this method of immunotherapy has markedly grown. The starting age is one of the factors that await establishment.
Stay Tuned,
J. Thompson, MD
Dear Kathy
I made it through one of the worst Oak pollen seasons that Florida has had with improvement in my overall sinisuitis and allergies. I did not realize how bad the season was until I went to my allergist for a regular checkup and she said the only people who were not overly bothered were those on SLIT. Everyone else has had severe problems. I also am not at maintenance level, so that says a lot for it.
Hi Kathy,
I don't use SLIT in my office. I only utilize SCIT (allergy shots) for ages five and above. There is a much longer history of allergy shot therapy and it is FDA approved. I choose to only practice FDA approved treatments but I know many other doctors, including some allergist have gone to SLIT.
Therefore I cannot comment on effectiveness of SLIT from my own experience (have not done it). But I am closely following the research, and reports on clinical experiences in other practices.
Currently, SLIT is not FDA approved. Yet more people are being treated with it every year in the U.S.
The issues I commented on in my posting remain unsolved.
But as you can see by Suzie's testimonial it can be effective.
If you have an interest in SLIT try to find a board certified allergist that does it.
Good Luck,
J. Thompson, MD
Hi Suzie,
I appreciate you sharing your experience. I suspect your allergist meant to also include patients on allergy shots (doing better with the season in addition to those on SLIT). People on allergy shots actually do better than those on SLIT (sublingual therapy) according to clinical studies I have reviewed.
SLIT and SCIT (allergy shots) help a lot of people all around the U.S. but SCIT is the only one FDA approved. There are lots more people on SCIT (in America) than SLIT but that may change once a lot of issues have been addressed (discussed in my posting).
I am glad it has worked out for you. SLIT is easier to do and tends to be relatively safe. Of course, when it works, life is better.
Best Wishes!
J. Thompson, MD
My allergist only uses SLIT. She will not even administer allergy shots to people like my husband who brings along his own syrum from PA. So that means that she was comparing SLIT to only antihistimines and regular asthma treatments. However, my husband on shots had a horrible allergy season and developed a sinus infection. I on the other hand constantly improved with my cronic sinusitis to the point that there was no visible sinus infection at the end of the season. I'm sold. The convenience of three drops per day to a drive of twenty miles one way every two weeks for a shot for him is wonderful. And as far as cost is concerned, we both pay about the same amount for his syrum and my drops.
suzie
Hi again Suzie,
If I had the success with my allergies you have had I would be sold on SLIT too. That is the beauty of medicine. Despite what clinical studies may show in terms of comparisons and outcomes, every individual has their individual experience to bank on.
I will probably offer SLIT to my patients in the future, once it gets FDA approved and more is learned about dose limits and other guidelines. Currently I have a success rate of about 80% with allergy shots (which mirrors clinical reports). This means of course, 20% of my patients won't be helped. But neither SCIT nor SLIT works for everyone.
I suspect your husband's allergies are more severe than yours. I doubt SLIT would do any better for him, but who knows. Maybe one day he may follow your lead.
To Your Health,
J. Thompson, MD
Dr Thompson,
My daughter is 5 years old with rast confirmed dog(12.5),ragweed and egg allergies.Any time she come in contact with grass she breaks out in an itchy rash and sometimes even hives. We have been seeing an allergist who said a few months ago that my daughter was doing the allergic march and she would greatly benefitfrom allergy shots. I went back in to see the doctor and he then said her skin problems were just eczema. Allergy shots wouldn't be a good idea. I am now considering slit therapy. I have an appointment next week with an ent that does slit therapy. We have tried zyrtec, claratin, tons of 2.5 hydrocortizone with nosuccess. Just wondering what you think? Is slit therapy worth a try or are allergy shots a better idea for kids?
Any information would be appreciated.
Thanks,
Lisa
Dear Lisa,
Thank you for your question. Your daughter may in fact be going through the "allergic march" based on her eczema and food allergies. I am glad she has been evaluated by an allergy specialist. You did not mention skin testing. Most board certified allergists do skin testing to further confirm allergy triggers. I assume her allergy test to grass was negative. If so, SLIT would not be helpful for her skin problem. Neither SLIT nor allergy shots are indicated for food allergy or eczema.
I think you should have her see a skin specialist (dermatologist). Follow up with your allergist for guidelines on food avoidances (egg etc.). She should be under the care of a board eligible or board certified allergist.
Learn more about the "allergic or atopic march": (click here)
Click here to learn more about eczema: (Eczema)
Good Luck!
J. Thompson, MD
Dr Thompson,
Thank you for your reply. The confusing part of the eczema is she really only develops it when she is in the grass. She had a skin test done at age 3 and tested positive to grass cats and eggs. She develops a rash with contact to grass and big hives sometimes. She also has allergic shinners,itchy nose and itchy eyes. She also had wheezing problems up to the age of 3. For one summer she had no eczema at all. She was on singular. She just had very terrible sleeping problems and aggressive behavior. So they took her off of it. Our allergist first told me that we needed to re-test her with the skin test because it is more sensitive to aero allergens. Then he said that the rast test would have picked up a grass allergy. The information is just confusing. I made another appointment this week and requested that she be re skin tested. I just am wondering if the grass could cause the eczema? In the winter she does not have a problem.
Thanks,
Lisa
Hi Lisa,
Hope things are going well for your daughter. Grass allergy may be identified by allergy skin testing or by Rast-IgE blood test. The skin test is considered a little more sensitive than the blood test. Someone very allergic to grass would likely show a positive finding on either test.
Summer eczema may be triggered by grass if there is contact with it. Eczema triggered by the grass pollen in the air (with no direct contact) is less likely.
The good news is, summer is three seasons away now (which is also the bad news).
Best Wishes,
J. Thompson, MD
Hi Doctor,
I live in Canada and over the last 1.5 yrs I have developed allergies. Slowly my symptoms have gotten worse. My nose runs every morning non stop - white clear mucus sometimes water like. It is irritated and my eyes also water. At times my throat feels itchy also.
I went to see 2 Allergy Doctors. The first told me I was allergic to dust and mold but was unable to do anything for me. He discussed shots but then ruled that out as I have to fly overseas for work occasionally.
Unhappy with the lack of diagnosis and miserable with the thought of continuing to go through a box of tissues every week as well as having flu like symptoms I sought a second opinion.
This time I was told I was only slightly allergic to cat dander and not allergic to dust and mold at all.
I can no longer clean my place and have to have outside cleaning as I tear up and sneeze if I were to do it. It's proving costly and I am at a loss as to what I can do.
Claritin works sometimes - however I don't want to pill pop for the rest of my life. I am only 35yrs old.
I sneeze about 20 times a day (which is greater than ever). My sneezes are loud and used to be much quieter - now they shake my entire body.
The second specialist told me I should consider changing my carpet to hardwood. That's a costly exercise when I am not 100% sure what I am allergic to. I practically begged him to do give me shots but he declined saying he doesn't know what I am allergic to although he could clearly see the irritation in my nose and eyes.
I'd like some more info on SLIT. Is it available in Canada? Can it be used for multiple allergies like cat dander and dust in my case?
Are there any other ways I can diagnose myself? Could it be I am suffering from something like sinitis versus allergies?
I am terrinbly confused. My nose is raw and I am miserable. I don't know what to do. Maybe I can pay privately for treatment - but I don't know what my next steps should be. Meanwhile costs for claritin is getting expensive I tried generics like citrizine but they do not work for me.
I can't understand how one suddenly gets allergies and why I can't be helped...
Any advice would be heartfelt.
Thanks
Vicky
We ALL know > immunotherapy WORKs...
We ALL also know that the Patient Complicance for Allergy OUCH SHOTs = < 35% for Studied" Patients...
We ALL know that SHOTs and Kids > NEVER are in the SAME Sentence.
We ALL know that Infant / Child Allergy MARCH > Likely leads to a LIFE Sentence of Allergic ASTHMA !
We ALL know that SLIT is SAFE & Effective as per the World Allergy Assoc. & endorsed by World Health Org.
We ALL know that U.S.A. Allergens are Uniform ...
We ALL know that ANY U.S.A. Dr. CAN Blood Test & Prescribe Drug FREE > virtually No Side Effects ( especially when compared to the MED's they Prescribe ) > Immuno-Allergy DROPs > whcih are Custom Formulated specifically to Neutralize the SOURCE of EACH Patient's Test ID'ed Offending Allergens.
We ALL know that allergy MED's ONLY Mask SYMPTOMs > Leaving Allergy Progression inTact > Progressing UnAbated to allergic ASTHMA !
Thus said...
While Anti-SLIT Medical Professionals stage their Delaying Tactics for SLIT ...
They offer NO Viable Therapy Alternative to DeRail the Progression of Allergy MARCH to Allergic ASTHMA in our KIDs !
Today's Allergy = Tomorrow's Allergic ASHMA !
Thank you for your comments
SLIT therapy (sublingual immunotherapy) may alter the "Allergic March", which is a pattern of progression from allergic eczema to allergic rhinitis and asthma, beginning in early childhood.
I don't think there is full agreement among doctors with many of the comments you posted as to what is known. Most experience and studies on SLIT are from Europe, the majority of which involve single allergens. In America multiple allergy triggers are often encountered and differ in some ways, from those in other countries.
There are many things we don't know. We do know allergy shots have been around several decades longer than sublingual drops. For this reason we know about long-term safety of allergy shots to a much greater extent compared to SLIT.
The FDA is aware of how other health agencies abroad deem SLIT therapy but is looking for some consistency and standardization of how it should be done before approving it.
I know that most children do fine with allergy shots once they have had a couple of them. They [allergy shots] are nothing like childhood vaccinations, with regard to pain. Many of my younger patients have had them and subsequently sustained reduced need for asthma medication (many clinical studies reflect this experience).
Many allergists will probably be offering SLIT once it gets approval (I likely will) in this country. Many allergists are not anti-SLIT, just pro-patient when it comes to any form of treatment that requires long-term doses (but yet has short-term experience and diverse protocols).
It sounds like you are sold on SLIT. I would be too, if my experience or interpretation of a treatment was the same as yours. But my several years experience in the practice of allergy leads me down the pathway of SLIT with a little more caution and patience.
But Good Luck to you!
J. Thompson, MD
While we do not agree, the Fact that you replied to my comments speaks well for you in light of this turbulent topic.
As you probably already know, recently the World Allergy Assoc. issued their 2009 Position Paper relative to Sublingual > citing > "Large pivotal double-blind, placebo-controlled, randomized clinical trials have confirmed the efficacy and safety of SLIT.
I would welcome a discussion between USA Dr.'s and World Allergy Assoc. Dr. to sort this matter out.
Hi, Your comments are appreciated. Yes, I am aware of the World Health Organization's (WHO) stance on SLIT. Efficacy and safety had been proven through various studies long before the WHO addressed this. There is no question about efficacy in my mind. SLIT is effective compared to placebo. Although there are no real good comparison studies with allergy shots, the ones that are available show greater efficacy for allergy shots. I didn't mean to state allergy shots are safer overall, because SLIT is safer regarding immediate reactions (severe anaphylaxis is extremely rare in the case of SLIT). My comparison (in the last reply) was from the standpoint of allergy shots being done for about 100 years and SLIT less than half that time. Therefore we know, at least in this country, more about long-term issues (regarding allergy shots). Again, you are right SLIT is safer regarding allergic reactions. No disagreement there. Finally, you should realize that I am a fan of SLIT. But I prefer to utilize FDA approved treatments (as do my partners in practice, and many of my colleagues). SLIT is not FDA approved. I pointed out in my article the shortcomings of SLIT regarding the lack of standardized doses and protocols (which greatly helps in studying and comparing effectiveness of a treatment). These standards exist for allergy shots. The FDA will probably approve SLIT once these hurdles are overcome. At that time I will likely jump on board. Take Care, J. Thompson, MD
I understand that this is anecdotal evidence, but my (now) 8 year old son started on SLIT therapy 2 years ago, with multiple environmental allergies (3 type of grass, ragweed, box elder, oak and maple). After two years of therapy, he no longer needs Singulair, nasal steroids, antihistamines, or frequent trips to the pediatric allergist. We only give him 10mg of Zyrtec once a day. His symptoms have dramatically decreased.
I understand that this is anecdotal evidence, but my (now) 8 year old son started on SLIT therapy 2 years ago, with multiple environmental allergies (3 type of grass, ragweed, box elder, oak and maple). After two years of therapy, he no longer needs Singulair, nasal steroids, antihistamines, or frequent trips to the pediatric allergist. We only give him 10mg of Zyrtec once a day. His symptoms have dramatically decreased.
Hi,
Thank you for your testimonial. SLIT therapy can work. But as you said, one report of success does not make a study. That said, I'm glad it has worked out for your son. We have seen similar results with allergy shots for more than 50 years. They (allergy shots for 5 years, while in grade school) worked for my daughter, who is now 22 years old and rarely requires any medicine for her asthma or sinuses. But of course, my personal experience is also not a study. The difference is allergy shots have been studied long enough to confirm such long-term remissions. We'll have to see over time how long your son's remission period is (neither SLIT nor allergy shots are curative).
Farewell,
J. Thompson, MD
I went through years of SCIT, and it worked great for a few years. But my pollen allergies (grass and ragweed) have gradually returned every year, to the point that it's now just as bad as ever. It's really disappointing to have gone through all of that just to have it return, especially so soon. I hope that SLIT gets accepted in the U.S., because I would love to give it a try. I don't want to go through all those doctor visits again (it's a long drive for me).
Hi Dr. Thompson,
Is it accurate to say that sublingual immunotherapy is not FDA approved, when in fact the only difference is the route of administration which makes it an off-label use of the FDA approved antigens?
As physicians, you have the right to use medications in an off label manner if the level of scientific evidence is sufficient and the use fills an unmet need, which one could argue is the case for sublingual immunotherapy. For environmental allergies, meta-anylyses have shown efficacy in allergic rhinitis and asthma in both adults and children. The level of evidence is now rate "1a" (the best rating possible).
Hi Amanda,
The route of administration is not the main issue regarding the lack of FDA approval. Yes, allergy shots with extracts are approved by the FDA. Sublingual Immunotherapy therapy (SLIT) is not approved despite being safer than allergy shots, as published in many reports, and easier to administer, and less costly. We are not certain why it has taken so long. Recall, I posted this article almost 3 years ago.
The FDA has taken several years to approve many other drugs that have shown promise in other countries. They have strict guidelines in this process which some feel, helps to protect Americans from medications that may be harmful or ineffective.
The fact that there is not a standard protocol for how to give it (regarding dose and schedule of subsequent doses) or how long to give it, doesn't help. Although the European experience with SLIT is in-depth, they only use one or two allergens at a time. Many Americans are allergic to more than a few allergens.
Physicians have the right to interpret studies and decide whether a medication or procedure that is not FDA approved. We (my practice) at this time choose not to. We provide allergy shots for our patients and are very pleased with the results (which have proven superior to SLIT in the studies I have reviewed). You have to be careful with meta-analysis. Although they can be useful, if you don't have good quality studies (within the analysis) that are large enough and pertinent to the population where you live, the results can be misleading.
Finally, treatments that are not FDA approved tend not to be covered by insurance. Hence, the savings you might realize with SLIT vs allergy shots may be much less.
Kathleen MacNaughton posted an article (3/2nd) on SLIT, but I realize you may have already read it.
Good Luck!
J. Thompson, MD
I'm allergic to just one pollen, which plagues many people in my area for two months of the year. My allergy symptoms get worse every year. This year I ended up taking multiple steroids to control symptoms. Have been researching allergy treatments, and am very interested in SLIT. (Traveling into the city once a week for allergy shots is not an option for me.)
I thank you for this informative post and your follow-up comments in which you make it clear that the best evidence indicates that SLIT, while often effective, is not as effective as allergy shots. That is not what I had been hearing from a couple of clinics in the city which offer SLIT.
Today I called a few allergist and found one who allows low-risk patients to administer allergy shots at home! This would solve my logistics problem with obtaining allergy shots. What do you think of allergy shots being given at home (for carefully screened patients only, of course)?
Thanks for all the info.
Hi,
I appreciate your comments and sharing of information. I am curious about the one, apparently seasonal allergen you are allergic to. Self-injected shots at home may be dangerous. If there is a severe systemic reaction you could lose consciousness before being able to give your self aid or call for help. You could die from a severe systemic reaction to an allergy shot. We don't allow home injections for this reason. Clinical or office settings have personnel and resources for immediate treatment with epinephrine (multiple doses if needed), supplemental oxygen and several other acute care medications.
Truthfully, I refused to give my wife and daughter shots in my home for several years. We live minutes away from a hospital and clinic but I didn't want to put them at risk even giving them the shots myself (and my wife is a registered nurse). They were forced to get shots in my office. My wife still gets them.
Perhaps allergy shots can be authorized to be given at a nearby clinic, urgent care or doctor's office. An allergist may be willing to send vials to a more conveniently located medical office or clinic.
I wouldn't recommend getting shots at home. I think the stakes are too high. Despite, my series of comments, SLIT would at least be safer, if available to you there. Who knows, it might be helpful for you. See a certified allergy specialist if you can.
Best Wishes,
J. Thompson, MD
Dr. Thompson,
Thank you so much for your thoughtful reply. I'm pondering safety concerns as well as efficacy and logistics.
I live in South Central Texas, and our most allergenic tree pollen pollinates from mid-December through mid-February. We call it cedar ("cedar fever"), but I think the real name is something like mountain juniper. For many years I had no problem with cedar, but about 10 years ago the symptoms started with just a mild cough starting around Christmas. Each year since then, my symptoms have gotten more severe. I seem just fine the rest of the year (while many people suffer from various environmental allergies year-round in this area).
I talked with someone at the doctor's office today. He said that this doctor's practice is exceedingly careful in setting dosages and that there have been no anaphylactic reactions to shots, in-office or at home, in over 20 years of their allergy practice. I know anaphylactic reactions are quite rare anyway, so I'm not sure how meaningful that is. But I do like a doctor's office that will spend quite a while on the phone with a prospective patient discussing their treatment philosophy, and why they do what they do. :-)
The first three weekly shots are required to be given at this doctor's office, under careful observation for possible reactions. My husband and I were discussing this a few hours ago, and wondered if people susceptible to severe reactions would be likely to show some sort of reaction early on in treatment.
Is it common for the most severe reactions to allergy shots to occur later in the course of treatment, without any indication of trouble after earlier shots? Or are there typically subtle indicators beforehand, or local reactions such as swelling at shot administrations?
Maybe it would be good to have an epi-pen in hand, just in case, if we decide to go this route. And we should find out exactly how far away our EMTs are also.
Once there was a car fire in our neighborhood (in the middle of a drought ... extreme fire risk) and it took the volunteer fire department over 25 minutes to arrive. My husband and neighbors kept things under control with garden hoses until the big guns arrived, but it was a tense few minutes.
Maybe we could drive about ten minutes into the nearest town and do our own allergy shots in the car in front of that fire station (after verifying ahead of time that they have epinephrine). Sorry, just realized I'm getting really punchy and silly in your comments section.
Thanks so much for your information and advice. We have more research and pondering to do. :-)
Hi,
Thanks for elaborating on your situation and allergy triggers. I see you and your spouse have been giving this issue a lot of thought. There are still some allergists that are willing to authorize home shots. As long as you and your allergists are on the same page regarding risk (even if very small and in the setting of having an epinephrine) of anaphylaxis and what to do. I realize that sometimes a decision to accept a level of increased risk is required. I understand and respect that, when all possible alternatives have been reviewed and considered.
Ultimately, you will decide on this, under the guidance of your specialist.
Regarding, likelihood of reactions, early or late: Anaphylactic reactions can occur anywhere along the course of shots, but, are more common during the early phase when the doses and concentrations (strength) of the injected extracts are being increased, at each interval (usually weekly). There is not always a preceding mild reaction or local reaction, in fact, clinical studies have struck down the concept of local reactions being considered as a signal for a subsequent systemic (anaphylactic reaction). Many patients have local reactions, some rather large, without ever having a systemic reaction. But then some people have severe systemic reactions with no local reaction. Sorry, I'm just giving it to you straight.
I do wish you the best of luck,
J. Thompson (And never worry about being "punchy" and/or "silly" in my comment section. I like both of those characters)
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It is great news that we are creating better means to treat allergies. I am a part of a family in which these very problems are quite common. SCIT and other extensive medications have always been a pain (no pun intended) to both my mother and my sister. I am curious about the ways in which foreign allergens differ from ours. How will these differences manifest themselves in treatment of American allergens? Are these differences significant enough to change SLIT's effectiveness when used in countries where trials have not been done?
Dear JAT,
Thank you for your comments. Allergens in Europe are not identical to allergens in the United States. I think there is enough experience with SLIT here (though not FDA approved) to expect similar benefits once many other details (discussed in the article) are worked out. The allergens that are unique to Europe would not be used in SLIT or SCIT in this country.
Many people would choose sublingual treatment over allergy shots if they offered the same benefits. If future clinical trials more consistently show as good or better results from SLIT compared to SCIT, the choice will be clear. We are far away from such a comparison as it stands. The fact that SLIT is not FDA approved is a major issue.
I hope your mom and sister are in the 80% that respond well to allergy shots.
Again thank you for your comments and questions.
J. Thompson MD