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Sublingual Immunotherapy: What the literature DOESN'T tell you

So sublingual immunotherapy (SLIT) will be officially approved for treatment of allergic disease in the near future.  Then what?  Allergists will begin to do it, and like any "new" treatment, problems will probably ensue.  I put quotations around the word "new" treatment, since some of us have been utilizing the treatment for a relatively long time.  In my own case, I have been using SLIT for 26 years, and over the years have refined my techniques, with the aid of my colleagues in our clinic and keeping up to date with the European allergy literature.  And the SLIT literature largely DOESN'T comment on multi-antigen therapy, mold treatment, food treatment, latex treatment, etc.   I sure don't have ALL the answers for using SLIT most effectively, but I've had ALOT of experience in using it in a clinical allergy practice--and that counts for something.  With that prologue, let's get "down and dirty" and talk about things that the allergy literature DOESN'T address with SLIT.  And my clinical experience.

1.  SLIT with multiple antigens works.  To my knowledge, there is only one recent article addressing SLIT in multiply-sensitized individuals.  More will be done in the future.  I've used SLIT for multiply-sensitized individuals without problems for years. 

2. Hi-dose preseasonal treatment for mold (Alternaria) works, but clinically the incidence of side-effects is higher than with pollen.  

3.  SLIT works exceedingly well for late-phase delayed reactions to antigens.  You know all about these patients.  They are the ones who have a delayed reaction 6-12 hours or even 24 hours after testing in your office.  We then do intradermal dilutional titration (IDT) on them, and find the strongest dilution that causes NO delayed reaction, and begin SLIT on that dose.  This advantage alone would make SLIT worth it.  These patients often have chronic sinus problems, and are often negative on immediate testing, and treating the delayed allergies works.  Like dynamite. 

4.  SLIT works for latex allergy and foods. I treated my first allergic patient for latex several years ago--she was a dental assistant who was seriously ill at work.  She quit her job, but remained highly sensitive to even trace amounts of latex exposure.  SLIT has allowed her to tolerate casual contact with latex with impunity. SLIT also works well for food sensitivity, even for foods that patients are highly allergic to. 

5.  SLIT can have side effects in unstable and/or multiiply-sensitized patients.    Don't get lulled into thinking that ANY dose of SLIT in ANY patient can be given with impunity.  No so.  In one of my asthmatics for example,who was  co-sensitized to alternaria, dust and grass pollen, she would enter the ER every June.  Hi-dose preseasonal treatment with grass caused a drop in peak flow (monitored at home while on therapy) and symptomatic shortness of breath.  The "standard" hi-dose preseasonal protocol was modified downward for the next grass season, and no ER visits or oral steroids were needed.  The literature has emphasized the effectiveness of hi-dose preseasonal treatment in the monosensitized individual, but "in the real world of allergy" many of our patients have multiple sensitivities and may respond differently.  Care must be taken!

6.  Multiple antigen threshold dosing for the polysensitized patient, coupled with selected hi-dose preseasonal dosing for a single major allergen works well.  Some patients have sensitivities to dust, tree pollen, mold, etc.  If they are HIGHLY sensitized in addition to a single antigen like ragweed, then the "layering in" of a preseasonal dose of hi potency ragweed treatment on top of polyantigen SLIT can be very helpful.  

In short, this has been my experience with SLIT...I continue to learn...both from the literature and my patients.  And the allergist beginning SLIT in his or her practice will have to do the same.    

Posted on Sunday, April 22, 2007 at 12:07PM by Registered CommenterGeorge F Kroker MD FACAAI in | Comments1 Comment

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Reader Comments (1)

I very much enjoy reading your blog, and I know a number of people who have benefited from SLIT treatment. I understand how it works for traditional allergies to foods like wheat dairy etc, but can it also help with non-celiac gluten intolerance or Salicylate sensitivities? Both seem to occur in my family. Thank you!

August 31, 2011 | Unregistered CommenterMeg

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