I'm thirsty...a drink of water wouldn't hurt, would it? Yet most of us are aware of water intoxication from using water (in a sense) "the wrong way".  Should we therefore regard water with a serious degree of danger? Should we all "just play it safe" and stop drinking water?  

...Such were the thoughts in my mind when I read the report in the August issue of The Journal of Allergy and Clinical Immunology by Cochard & Eigenmann entitled "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy".  

In their article, they present 2 cases of patients who suffered serious consequences when they took undertook SLIT.  Each patient had stopped prior SCIT also because of side effects.  Their conclusion?  "Special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."

hmmm.  And as I showed above, water is not totally safe either...

As some of you know, I've used SLIT for 29 years (this coming Feb), and as someone who has had not inconsiderable experience in treating patients who have experienced prior anaphylaxis from injection immunotherapy, I just have to weigh in on this one. I think the following comments are in order:

First, remember the literature---most of the published European literature is on monosensitized patients.  Both of the patients reported in the article were multiply sensitized.   

Secondly, the literature comments on the use of protocols designed for the stable allergy patient--the protocols weren't specifically designed for highly sensitized patients with prior reactions to SCIT.  

Thirdly, why would one give an ultra-rush protocol to patients previously found so reactive to SCIT that they had to discontinue it.  In short--what's the rush?  Looking for trouble?  

Fourthly, I have a suspicion that the total allergy load of at least one of the patients was not completely addressed. Something was missing.  Here's the story--the first patient (a 14 year old girl) was successsfully able to work up 8 drops a day with no major problem, but then 1 week later--at home--she reported a severe asthma attack together with mouth itchiness immediately after SLIT, lasting several hours.  Well, how come she could handle the SLIT the other 6 days without problems?   Most likely, she has some other stressor affecting her system, and partially limiting her response to the treatment...since she was birch, grass, ragweed, and alternaria sensitive, could she have had a hidden concomitant food reaction going on?  How about a hidden cereal grain allergy since she's grass sensitive?  Or a fruit sensitivity to banana, melon, apple, etc. ??  Furthermore, the authors were not, from my understanding, treating her alternaria allergy--just grasses. What were the Alternaria mold counts on the day of her severe reaction?  Incompletely treating allergy load doesn't help the situation here.  

In my opinion (after nearly 3 decades of experience), these authors would have more likely had a successful outcome with both patients if they used multi-antigen threshold dosing, and perhaps selective preseasonal moderate dose therapy as an add-on, after thoroughly looking for hidden food sensitivies that could make  these patients brittle.  It works for me.  

Indeed, often when I see a patient poorly tolerating SCIT, (like these 2 patients), it's because of usually only 2 reasons:  either the doseage administered was technically a failure, or there was a hidden sensitivity in the patient that hadn't been addressed, and stressed their system, making them "brittle".  More often, it's choice number 2 rather than choice number 1.  Although it could be either.

Soooo, what's the verdict?  I agree with the authors conclusions--"special caution should be exerted in patients with a previous history of side effects on immunotherapy, because SLIT does not represent a totally safe immunotherapy procedure."  Yes, and water can be poisonous.  In my opinion, a better title for the article (rather than "Sublingual Immunotherapy is not always a safe alternative to subcutaneous immunotherapy" would be

"Sublingual immunotherapy  in ultra-rush protocol to multiple sensitized patients who may have other hidden sensitivities is not always a safe alternative to subcutaneous immunotherapy" would be a much better title.   

My real fear is that the typical allergist likely perusing this article will go AHA!  SLIT ISN'T SAFE!  SEE! SEE!  And he/she will settle back comfortably into the complacent shot-giving attitude that is so common now-in-days, making the search for a better form of immunotherapy nonexistant.  And you know what?  The allergist is being bypassed in all this--by the ENT physicians and others who are increasingly using SLIT. Most ENT's  know SLIT can have side effects, and the one's that are friends of mine aren't using ultra-rush protocols on their patients either...

The search for a "universal" dose of SLIT that fits all patients in allconditions is nonsense.  To apply the European protocols for monosensitized patients to multi-sensitized patients with severe SCIT reaction histories should only be done at the doctor's (and patient's) own peril...SLIT is incredibly versabile, and like any oral therapy (antibiotic treatment immediately comes to mind) different dosing protocols, depending on the condition you're faced with, make intuitive sense.  (I won't treat an acne patient and a lyme's patient with the same dose of doxycycline, would I?)

So think about these things, and while you're at it--pour me a glass of water, would ya?

Later, Dude