Q&A: Sublingual immunotherapy viable for treating respiratory allergy in children

Key takeaways:

• Sublingual immunotherapy (SLIT) may be an acceptable alternative for children with respiratory allergies who fail to achieve control of their symptoms or suffer from side effects with other treatments.
• Side effects with SLIT tend to be local, oriented around the mouth, and dissipate once treatment is underway.
• Shared decision-making enables patients to play an active part in determining the course of their treatment, ensuring adherence and successful outcomes.

Sublingual immunotherapy does more than relieve symptoms of respiratory allergy in children. It also modifies the disease, according to a review published in Allergy and Asthma Proceedings as part of its Allergen Immunotherapy (AIT) Primer.

“Immunotherapy is the only treatment that in fact leads to a change in the immune system and can help turn off the allergic response in the patient,” Michael S. Blaiss, MD, FACAAI, author of the review, clinical professor of pediatrics at the Medical College of Georgia in Augusta and executive medical director of the American College of Allergy, Asthma & Immunology, told Healio.

Sublingual immunotherapy (SLIT) is safe and available in an FDA approved dissolvable tablet form, with minimal local adverse effects, Blaiss said. Yet he also advises that shared decision-making between the doctor, parent and patients when they are old enough is essential to care.

“It’s really offering the patient to be a partner with you in care,” he said. “They may want it, they may not want it, and that’s OK. But if you look at the data, it is effective.”

Healio spoke with Blaiss, who also is an allergist at the Good Samaritan Health Center in Norcross, Georgia, to find out more about the pros and cons of using this treatment in a pediatric population.

Healio: When should providers escalate care from other treatment to immunotherapy?

Blaiss: It really depends on the patient, the degree of patient symptomatology and quality of life. There are lots of over-the-counter treatments for allergic rhinitis, like non-sedating antihistamines and intranasal corticosteroids. When these medications are not controlling the problem, or when patients have to take them constantly to control the problem, or are tired of taking medications, or are having side effects from the medication, those are all reasons for trying immunotherapy. Many patients will say they are tired of taking medicine every spring or fall and that they would rather do something to try to get rid of the problem.

Healio: What are the differences between sublingual and subcutaneous immunotherapy?

Blaiss: One is safety. SLIT has a much lower rate of systemic reactions. Subcutaneous immunotherapy has more serious, though rare, side effects, as there are patients who do develop anaphylaxis and there are rare deaths each year. But with SLIT, side effects are local to the mouth, and most of these tend to go away very rapidly once the patient is under treatment.

Second, patients do not have to go to the physician’s office for SLIT. After the first dose, it can be administered at home. Obviously, you can’t administer subcutaneous therapy at home due to the possibility of anaphylaxis. Patients may not have the time to regularly go the physician’s office for injections, usually starting at once a week.

We have two really good types of treatment here: sublingual and subcutaneous. We should be using shared decision-making in determining which approach to use. We should be explaining the different benefits, risks, causes and outcomes associated with each treatment and then discuss with patients what works best for them.

Healio: Your review highlighted multiple studies about SLIT use. Are there any specific findings that you would like to spotlight?

Blaiss: Clinicians need to understand that SLIT tablets are the only approved SLIT in the United States and available for house dust mite, ragweed, and northern grasses. They went through rigorous phase 3 studies for FDA approval. SLIT drops are approved in other countries, but not in the United States. Any drops used in the United States have not gone through clinical trials to prove their efficacy. If a doctor prescribes them, then it is off label, and it is not covered by insurance.

Also, we just don’t have enough data yet to show that SLIT will prevent the development of new allergies or asthma. The results are mixed, and we need further and better studies to really determine if early use of sublingual immunotherapy will prevent the development of asthma or other allergies.

Healio: Do you have any recommendations for doctors who want to begin incorporating shared decision-making but who are not familiar with it yet?

Blaiss: In the past, if the doctor said it, then that’s what should be done. But over the past 15 years or so, we’ve been in the age where “Doctor Google” has already made the diagnosis, and we’re just asked to prescribe a treatment.

We’re trying to achieve a balance. As clinicians, we should explain the condition and the different options for treatment. What are their pros and cons, the costs and outcomes? And then we have our patients. What are their beliefs, preferences, values and concerns?

The way I explain it to clinicians is that it really doesn’t take any more time in an office setting if done correctly. The ACAAI and the Allergy & Asthma Network developed a shared decision making tool that is on their websites that go through all these areas in nonmedical language for allergen immunotherapy. They ask questions like “Do you have needle-phobia?” and “Can you come to the doctor’s office once a week for an injection?” and “Do you have a problem taking medicine daily?”

This tool tries to see what will work best for the patient, because there are a lot of data showing that shared decision-making improves adherence and therefore outcomes because the patient has a stake in what was decided.

There are times when there is only one treatment. If someone is having anaphylaxis, there is no shared decision-making. We also have patients who come to us and ask, “Doc, tell me what you would do?” or “What would you do for your child or your mother?”

But there are times where, like with allergen immunotherapy, there isn’t a right or wrong. They’re both effective. They both work. The doctor has to say, “There are two possible, good options here, and there’s always a third option to do nothing. I would like to get your opinion on which one you think you could do better with.” By getting the patient’s input, if it improves adherence, then we’ll achieve better outcomes.

I often hear doctors say they don’t want to engage in these conversations because they take too long, but they really don’t. Doctors may say that it is a different way of taking care of patients and that they are not going to change. Numerous studies have shown that doctors think they are doing shared decision-making, but when you ask the patient, the patient says that no, they’re not. We’re really not giving them all the information that they need to make an informed decision.

Healio: What are the key takeaways from your letter for providers who want to expand or improve their use of SLIT for respiratory allergies in children?

Blaiss: If they’re seeing patients who are not doing well, having side effects, tired of taking medicine or eager to try to get rid of the problem, they should refer those patients to a board-certified allergist. They need to make sure that these patients truly have allergies.

We see a lot of patients with nasal conditions. In fact, I had two or three this week who came to me through a referral for nasal allergies, but they didn’t have allergies. There are a lot of things that cause nasal congestion. These patients need to have a good workup. They obviously need to be tested to determine what they may be allergic to. Then, there should be a discussion about whether immunotherapy is something that they should have. Blood tests for allergies alone do not diagnosis allergies. For example, patients come in and say that they have a blood test from another doctor saying that they have ragweed allergies. I go over their history and say that ragweed starts in late summer and lasts through the first frost. So, I’ll ask if they have problems in September and October. They say no. I’ll then ask if they have any sneezing, nasal itching, and/or eye problems in September and October. They say no again. Well, then that test didn’t mean anything.

In other words, they can still have IgE antibodies to pollen and other allergens in their blood, but it doesn’t mean that’s what causing their symptoms. As in all medicine, you really have to do a history and a physical exam, and you have to make sure that you are treating the right condition with the right treatment.

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For more information:

Michael S. Blaiss, MD, can be reached at michael.blaiss@gmail.com.