Allergy Meds Under the Tongue

iStock_000044075022_MediumPlacing a tablet with an allergen under someone's tongue to help ameliorate allergic responses has been around for a bit and is known as 'sublingual immunotherapy', but now, as Rick and I discuss on PodMed this week, the strategy was tried in people with moderate to severe asthma who were allergic to dust mites to try to reduce asthma attacks or exacerbations when corticosteroids were tapered.  Wow, that's a mouthful in describing the study population, but the upshot is it is desirable both to reduce corticosteroid use in these folks but also to avoid hospitalizations relative to asthma attacks. The study was published in JAMA, and the news is good. The two groups who received the allergen under their tongues did see a reduction in their exacerbations even when the steroids were reduced and discontinued.

Rick says the benefits to the treatment, abbreviated 'SLIT,' are multiple, and include ease of administration (no one likes shots!) and a reduced dosing schedule over months rather than continuously, as is seen with allergy shots.  Potential downsides include slightly less efficacy relative to injections and some oral itching and associated mouth symptoms in about 20% of the higher dose SLIT group. Do these results warrant expanded investigation into other groups of allergic folks, and perhaps tablets with more than one allergen?  Stay tuned, as we agree that the likelihood seems high.

Other topics this week include 'antibiotic stewardship' and risks of smoking cessation drugs in the Lancet, and methods to reduce Clostridium difficile infection in the hospital in JAMA Internal Medicine. Until next week, y'all live well.

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Claire Palmer May 7, 2016 at 1:27 pm

In 2005, my daughter was diagnosed with severe growth suppression and adrenal suppression secondary to inhaled and intranasal fluticasone propionate at the CHOP Growth Center. Her diagnosis was very controversial, but it was confirmed. When her inhaled steroid dose was reduced to one-quarter of her original maintenance dose, her basal cortisol returned to the normal range.

At the time of diagnosis, her basal cortisol was 0.3 mcg/dL (thirty times below the bottom of the normal reference rage), a potentially life-threatening condition. Her HPA axis took two and half years to recover full function. She had no discernible allergies by skin test and total IgE.

We cleaned up our home environment and hoped she would stay healthy on the lower dose. (Her new asthma doctor had switched her to a bio-equivalent dose of budesonide. Her original asthma doctor, whom she'd seen at CHOP for years, refused to accept the diagnosis from the Growth Center, so we were forced to find help elsewhere.)

Two years later, her skin tests converted; she was allergic to many things (including dust mites). She was placed on SLIT for about five years and is now off ALL asthma maintenance medication. She follows her asthma action plan when sick, which is rare; and she was a little girl who was sick from November through March for years. She still uses Patanase antihistamine nasal spray every day, which I think she could drop if she'd perform nasal washes.

I had a asthmatic child who could not tolerate the drug that was meant to help her. In fact, I would argue, the drug that was meant to help her actually hurt her and created the need for more drug. Allergy immunotherapy is the closest thing to a cure that we have. As I understand it, SLIT has been used in Europe and Australia for decades with success. It does not carry the risk of anaphylaxis that injectable allergy immunotherapy does with every single injection for the duration of treatment.

Yes, SLIT requires a commitment that other treatments do not (we used a liquid form that had to be refrigerated). Like injectable allergy immunotherapy, it probably will not be as effective in an "unclean" living environment. But, trust me, parents of sick children are highly motivated to help their children stay healthy, especially if the treatment represents a "de facto" cure. The drugs used to treat asthma and allergies are very expensive. Insurance coverage for young adults with a diagnosis of childhood asthma is expensive and not guaranteed. My daughter took prescription Claritin, Fluticasone (inhaled and intranasal), Serevent, and Singulair every single day for years...and she still got "scary sick" with alarming frequency. We spent thousands of dollars on insurance co-pays every year and were grateful we had the insurance coverage.

Both of my children had an asthma diagnosis. Both of my children were diagnosed with a number of environmental allergies. Both of my children were on SLIT for about five years. Both of my children are off all asthma maintenance medications (my son still takes Claritin most days and also refuses to try nasal washes).

SLIT works. It is expensive. It should be covered by insurance plans.

BTW, my daughter is finishing up her sophomore at JHU.

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Elizabeth Tracey May 13, 2016 at 10:50 am

Wow, what a journey! Thank you for sharing, and all the best to your daughter!

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dr.Muaaz Alkanj May 7, 2016 at 9:21 am

Great job

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