Sublingual Immunotherapy (SLIT) patient information
Prevalence: Research estimate that 17% of the population has medically significant allergies. At USNH Okinawa, most are currently treated by self-medication, primary care and Otolaryngology with an emphasis on environmental modification, avoidance, topical nasal steroids and antihistamines. Approximately 10% of this population is not adequately controlled in this manner and require immunotherapy to decrease symptoms.
Indications: Immunotherapy including both subcutaneous (shots) and sublingual (drops) are indicated for patients with allergic rhinitis or allergic asthma that is not managed with appropriate avoidance, behavioral modification, environmental modification and current pharmaceutical therapy. It is also indicated for patients with documented allergies and nasal polyps and is important for surgical outcomes especially for allergic fungal sinusitis.
Safety: No reported fatal reactions from SLIT in literature. Greer – Phase 1 study, 2006 with local side effects (mouth itching), rare exacerbation of asthma or hives, one case of anaphylaxis and one case of systemic reaction. Anecdotal reports via American Academy of Otolaryngic Allergy (AAOA) of two anaphylaxis in SLIT for severe peanut allergy patients. Of note, no deaths in 15 years of SLIT worldwide. Adverse event rate 0.83 per 1000 doses in 286 children receiving 96,000 sublingual doses none of which were life-threatening (Di Rienzo 1999). SLIT is safer than shot therapy.
Efficacy: Cochrane Review: SLIT efficacy in allergic rhinitis (2003) showed a symptom decrease by 42% and medications use decrease by 43%. “Overall there was a significant reduction in both symptoms (p=0.002) and medication requirements (p=0.00003) following immunotherapy.” Comparable medications showed a decrease in symptoms of leukotriene receptor 5%, antihistamines 7% and nasal corticosteroids 17%. SLIT was not statistically different from SCIT (allergy shots). SLIT has also showed a decrease in onset of asthma in atopic children (38% onset in control, 5.8% onset in SLIT after 3 yrs, p < 0.001) and a decrease in symptoms and medication use in patients with allergic asthma that persisted for 10 years after cessation of SLIT. Also of note, compliance has been demonstrated to be better for SLIT at three years (95% pollen, 97% dust mite) than for SCIT (50%) at one year. CDRs Clenney and Bloom demonstrated an improvement in nasal and eye symptoms for patients converted from shot immunotherapy to SLIT at NMCP which is being presented at the Virginia Society of Otolaryngology Annual Meeting May 1, 2009.
PATIENT ALLERGY DROP INSTRUCTIONS:
Priming the dispenser: Your dropper bottle dispenser has been specifically calibrated to deliver a specifically calibrated dose of antigen with each pump. To begin using your dispenser, you will need to prime the pump by first removing the colored safety clip and depressing the pump several times firmly and quickly, until a drop is released.
Taking your drops: Removing the colored safety clip, then rest the dispensing arm of the pump on your lower front teeth to administer the drops. Depress the pump firmly and quickly, so that the dose is released under your tongue. Replace the safety clip.
Inhalant Antigens (red label) and Food Antigens (blue label): Use ONE dose under the tongue three times daily. Hold the drop under the tongue for 20-30 seconds before swallowing. Your bottle should last about 3 months. If drops are missed earlier in the day, 2 or 3 drops may be taken consecutively at the end of the day. Taking a total of three doses each day is important to continuously stimulate the immune system to build tolerance to these antigens. When possible, it is ideal to take food drops 20 minutes before eating.
RESPONSE TO SUBLINGUAL IMMUNOTHERAPY:
Phase 1 (0 – 3 months) Initial oral tolerance: During this phase, your body adjusts to treatment and symptoms can improve. You may experience minor oral itching, but this will lesson as tolerance begins.
Phase 2 (3 months – 2 years) Initial desensitization & symptom relief: During this phase, as symptoms decrease, your body takes steps towards changing your allergen tolerance. You might feel tempted to stop your treatment because you feel better…but don’t. By continuing treatment, your body develops long-term benefit.
Phase 3 (2 – 5 years) Symptom reduction & long-term desensitization: As symptoms continue to improve, your body increases its allergy tolerance. This long-term learning is needed for you to stay symptom-free after treatment.
SIDE EFFECTS OF SUBLINGUAL IMMUNOTHERAPY:
Minor local adverse events including orolabial itch (itch of mouth, tongue and lips) will be recorded without a change in protocol.
Moderate adverse events including mild bronchospasm (asthma wheezing), gastrointestinal distress will result in a decrease in the amount of allergen administered with a spit technique if symptoms persist (place under tongue but do not swallow).
Severe adverse events including asthma not controlled with inhaled steroids, anaphylaxis, upper airway compromise including stridor, acute bronchospasm requiring more than 1 albuterol nebulizer treatment, and recurrent severe gastrointestinal symptoms will likely have SLIT stopped.
Important Safety Note: In the unlikely event that you experience swelling, wheezing or difficulty breathing, take an antihistamine and go to the Emergency Department at USNH Okinawa. If increasing symptoms consider using a Twinject auto-injector epinephrine pen.
You can anticipate needing to be seen in the ENT clinic every three months during the duration of your therapy. You can anticipate staying in the clinic for 2-3 hours after the first administration in the clinic of each new SLIT dispenser.
Modification of Allergychoices incorporated Drop Instructions, Patient FAQs, Allergy Drop Program and Treat the Cause Brochures on November 24, 2009 by David Bloom, MD