Chances are most of us got to work today in a car.  My car is a modest Honda Accord.  Gets the job done.  But if I was 'ol Bubba, I'd want a big 4x4 with a gun rack and probably the capability to get thru some bad gullies to my deer stand...right?  Well, the car makers got it right.  They design cars for different purposes.  It's a versatile form of transportation. But different cars "work" for different people.  We all "know" that, right? 

 Which gets me to SLIT. 

You see,  what's really missing in every one of the papers published on SLIT is perspective. Oh sure, we talk about its safety, its effectiveness, and its convenience.  But I've used SLIT as my technique of choice for immunotherapy for over 26 years--and I'd say the biggest advantage of SLIT can be summed up in one word:

Versatility.   

Huh?  What?  

SLIT can be used via a number of specific techniques, depending on the clinical situation;  in my use of SLIT for a quarter century, I've found it useful in 5 different ways:

1.  Multiple antigen threshold dosing (via IDT) for multiply sensitized patients who have chronic perennial symptoms from multiple allergens--dust mite, dander, molds, etc.  Believe me, you'll get into trouble when you try to escalate Ragweed in an unstable chronically allergically-reacting perenially sensitive patient who is reacting day-to-day to dust and danders.  Been there.  Done that.  But multiple-antigen threshold dosing is dynamite. 

2.  Working off the delayed reactions to mold, treating with low dose threshold dosing for delayed mold reactors.  i.e., reading the delayed wheals the NEXT day, and  treating off the strongest negative delayed wheal (via IDT) in people with little or no immediate reaction to molds, but strongly positive delayed reactions.  Works like a charm.  This advantage along would make SLIT "worth it" to consider.

3.  Prerseasonal rush immunotherapy for monosensitized patients who have an isolated pollen allergy, used via the European tradition.  Adopting the European tradition for Parietaria pollen to Ragweed, for example, works great. 

4.  Modified IDT-based rush immunotherapy for mold allergic patients, using a protocol recently discussed by Saporta & McDaniel in ENT Journal August 2007, pp 493-497.  This works well for Alternaria mold in my experience, while traditional preseasonal rush via the European tradition gives more side effects and is tricker for molds than for pollens.  Starting with a dilution #4 typically for Alternaria, then moving to dilution number 3, sequentially as McDaniel describes works great in the winter "off season" when Alternaria isn't around.

4.  Traditional build-up dosing for patients with severe IgE-mediated food allergy to peanut and other severe food allergies.  Starting with several nanograms of peanut (a number 9 IDT dilution typically), and slowly working up in a conventional "build-up" manner works well.  

These techniques all work.  And I laugh when I read articles and commentaries in the current allergy literature discussing "what's the best dose for SLIT?" which seems to be the current "debate du jour" for SLIT.  You see, it's really quite simple:

The best dose for SLIT depends on the type of allergy patient being treated.  Any attempt to find a "universal, standardized protocol" for SLIT to cover all types of allergy patients is absurd. 

A reader of my blog wrote to me expressing this sentiment (and his frustration):

 "The AAOA is talking about a SLIT protocol that abandons 40 years of quantitative testing tradition when dosing for SLIT--one size fits all, rapid escalation, wait until you have a reaction to back it off.  How can this be?" 

 

All I can say is, "I hear ya, pal".  It's absurd to suppose that a "universal" SLIT protocol can be found that will be appropriate for all patients.  The Holy Grail will never be found.  To have a single protocol for SLIT immunotherapy makes about as much sense as an Infectious Disease doctor having one dosing protocol for an antibiotic (doxycycline, for example).  Doesn't it make sense the dose and schedule depend on the infection and the status of the patient?  Well, it's the same for SLIT folks.  The dose and the duration depend on the immunological status of the patient. 

My suggestion?  Simple:

Before the AAOA comes up with any protocol, have the AAOA do some real research and digging...and talk to some of the "experienced clinicians" who have been out there using SLIT for years.  Our own clinic has over 100 years of SLIT experience divided between the 6 physicians in our clinic.  We've made alot of mistakes, and alot of "blood, sweat and tears" have gone into  coming up with protocols that finally work for our patients.  We teach these protocols at our annual SLIT conference.  And the attendees have come back to us year after year, and gratifingly have said our protocols work. 

Final thought?  I don't want the AAOA to have to go through the same mistakes we've made.  Because I care about the AAOA...and I care about my patients.  SLIT is versatile.  And it's just too plain and versatile a tool to hamstring to "one universal protocol"  In cars, one size doesn't fit all.  And the same holds true for SLIT.

Later, Dude.