Frequently Asked Questions
Find more answers about Allergenuity Health and SLIT here
General Clinic Topics
Direct Care is a fresh (and also somewhat old school) healthcare model being embraced by physicians who want to increase patient access to high-quality healthcare and rebuild the foundation of that – a strong, lasting, mutually respectful, and trusting relationship between a patient and his or her doctor. With direct care, you enter into a relationship directly with your doctor, and your doctor is only accountable to themselves and to you.
No insurance companies placing endless and impossible hoops to jump through, denying claims and demanding that your physician change their treatment recommendations in order for your treatment to be covered, regardless of it meaning that you would not get the best treatment for you specifically.
No business administrators saying your doctor cannot spend the time with you that you both need together to appropriately assess your ailments or discuss your treatment options, because the office needs to increase their patient numbers in order to have a chance of more claims going through so that they can be reimbursed enough to pay for the billing and coding staff they had to hire in order to fight with insurance companies all day long.
No non-medical executives thinking that physicians are interchangeable and that any patient can be seen by any doctor with the same results, ignoring the immense personal value to both the patient and the physician of having an enduring and trusting patient-doctor relationship, as well as the incredible health benefits that come from you seeing a doctor with the expertise you need who also knows you very well.
With direct care, all of that goes away, and things reset to simply you and your doctor.
The direct care model has had the most momentum in the primary care area, with the Direct Primary Care (DPC) movement growing over the past decade as more and more doctors and patients have grown extremely frustrated with the typical insurance-driven healthcare system in the US. Two innovative features of the DPC movement have been to (1) limit the number of patients per physician so that a physician has time to be available when his or her patients need access rather than always being fully booked out for months, and (2) to use a recurring monthly payment model to cover a range of services including your physician’s time providing you medical services, your access to better direct availability with your physician when you need him or her, common tests you will likely need, and basic procedures you may require at some point. Specialized treatments, procedures, or tests often have a separate cost, but usually those costs are much more reasonable than in the insurance-driven system due to direct care doctors being able to avoid the insurance-driven system’s price inflation tactics and thus pass on the savings to patients. Prescription medications may even also be available at an extremely discounted and reasonable cost.
More specialists are now also realizing the potential benefits a direct care model can offer both their patients and themselves (such as sanity!) and are choosing to take on the cumbersome process and risk of extricating themselves from the insurance-driven system and rebuilding on their own as well, with hopes of practicing medicine the way they’ve always wanted to – with only you in mind. The direct primary care and direct specialist care model creates happy and healthy patients and doctors, which in turn creates happier and healthier communities. It also reminds patients that you have the right to choose your physician and where you get your care, and you can choose to get care directly from your trusted physician without interference.
We look forward to meeting you! Here is a breakdown of the general flow you can expect from your first visit with us:
Intake Admin Services (15 mins): Your first visit will start with collecting any demographic or background information still needed, though if you have filled out the enrollment paperwork online you may already be all set. Feel free to ask us any questions you may have about the logistical or financial aspects of your future care with us.
Medical Services (60-120 mins, based on the appointment you have set up): Next you will meet Dr. Schroeder. Together you will discuss your medical/allergy history, your lifestyle habits, your goals regarding your allergy health and treatments, your concerns or fears regarding your health and treatments, and your general questions. Dr. Schroeder will listen and then answer your initial questions as best as possible. She will check your vital signs and do your physical exam, and then she will discuss her thoughts with you on any appropriate testing needed at that time to get additional initial diagnostic information. You will then move on to the testing part of the appointment, which may include allergen skin testing, breathing tests, and/or some sublingual antigen drop test doses. After information has been obtained from your testing, Dr. Schroeder will review with you the results and her initial thoughts regarding a treatment plan, which may include any or all of the following: environmental control measures, appropriate medications, immunotherapy options, management of immune stressors, and dietary management. In the remaining time, she will go deeper into the details of her treatment plan as appropriate and answer any questions you may have about her treatment recommendations or this overall process.
If sublingual immunotherapy will be part of your treatment and Dr. Schroeder has enough information to formulate your initial treatment bottle(s), she will put together your bottle(s) and you may do a test dose if needed and leave with your bottle(s) in hand the same day. However, if bloodwork is needed, this will be performed after the visit, and Dr. Schroeder may want to wait to see these results before further formulating your immunotherapy treatment plan and your initial drops bottle(s). In that case, she will review with you the appropriate follow up steps related to your specific conditions and situation (including how far away you live, especially if out of state) in order to get you started on your sublingual immunotherapy program as smoothly and safely as possible. Some common next steps would include one of the following: (1) scheduling a follow up appointment – either in the clinic or via appropriate phone/telemedicine methods – to review your results in detail, do any additional testing needed (if in clinic), and discuss appropriate treatment options (often for more complex conditions or instances in which significant bloodwork was needed before treatment options could be developed and discussed), (2) returning to the clinic just to pick up your sublingual immunotherapy bottle(s) and do a test dose in-clinic if needed (a quick, 10 minute process), or (3) having your sublingual immunotherapy bottle(s) mailed to you.
Concluding Admin Services (15 mins): Your appointment will conclude with a discussion of when your next in-clinic follow up appointment should occur. Then we will review your enrollment papers with you, your Program or Fee For Service plan details, and answer any remaining questions you have about the logistical and financial aspects of your care with us. Once you are all fully set up, you will be on your way, hopefully feeling informed and hopeful about the future, and we will be in touch with you as appropriate per your treatment plan or when we receive your additional results!
We want you to have enough time during your initial appointment to get your initial questions answered, so we have allowed for our shortest initial visit appointment time to give you up to 1 hour with your physician (taking about 1.5 hours overall including admin services). Depending on your reason for establishing care with us, we will help guide you regarding what appointment length to reserve, and you may reserve up to 2 hours with Dr. Schroeder if desired. Should you still want or need additional time regarding your initial questions, we will be happy to work with you to set up an additional phone consult time or another in-clinic consultation with Dr. Schroeder at any time.
Allergenuity Health acknowledges the tremendous known advantages and untapped potential of Sublingual Immunotherapy (allergy drops) treatment, and we have chosen to focus on making comprehensive and innovative sublingual immunotherapy options available to all those who are interested and could potentially benefit from them.
For more explanation on our reasoning and (much) more useful information on Sublingual Immunotherapy, please check out the Sublingual Immunotherapy Topics FAQs section below and the information on the Sublingual Immunotherapy services page.
At Allergenuity Health, all sublingual immunotherapy treatment programs are designed and tailored specifically for each patient’s needs and goals by Dr. Nikhila Schroeder, a board-certified allergist with a special interest and extended experience in retraining the immune system safely with sublingual immunotherapy (SLIT). Your SLIT treatment bottles are filled at Allergenuity Health (not off site by someone else), and your SLIT treatment plan is actively managed throughout the entire process by Dr. Schroeder directly (not sourced to an outside company).
Our sublingual immunotherapy mainly uses FDA approved and regulated commercial antigens. These antigens are prepared by the supplier companies by the strategic collection of the individual source material (specific pollen, food, animal allergen, venom, etc), purification, and then suspension in a liquid solution containing components to stabilize the antigenic proteins and prevent microbial growth.
Can I do Allergy Shots (SCIT), Oral Immunotherapy (OIT), or Rush Sublingual Immunotherapy (Rush SLIT) at Allergenuity Health?
Allergenuity Health has chosen to focus our efforts on providing quality, personalized, and comprehensive sublingual immunotherapy (SLIT) programs for the many patients that could greatly benefit from having this hard-to-find option available. As such, for now we will not be providing allergy shots or oral immunotherapy services.
Rush SLIT will be available at Allergenuity Health for targeted seasonal allergen desensitization. A Rush SLIT treatment procedure may be considered for other appropriate uses on a case by case basis.
Yes. Getting answers to simple health care issues directly from your trusted physician does not have to be inconvenient, frustrating, full of delays or middlemen, or simply impossible! If you are an established patient at Allergenuity Health, you may email Dr. Schroeder directly for important basic medical issues related to the medical conditions she is helping you with and she will get back to you as soon as she can. If you are in an Allergenuity Health Program, you may also text Dr. Schroeder directly for these same types of questions. These emails and texts will also be recorded in your medical record at Allergenuity Health for reference later if needed.
If you are in an Allergenuity Health Program, the answer is yes. Being able to contact Dr. Schroeder outside of our business hours via text for non-urgent issues and via phone for urgent issues is a convenience available to Allergenuity Health Program members.
How many scheduled follow up appointments are needed per year for Sublingual Immunotherapy (SLIT allergy drops) treatment?
Depending on your personal treatment plan and how far you are traveling to come see us, we can decide together how to best plan for follow up during your buildup and maintenance process. Many local families come for either a brief updose appointment or a more thorough follow up appointment every 3 months for awhile, then spread out to every 6 months at higher doses, and then are seen yearly during maintenance. Many out of state families that fly in or drive significant distances may come every 6 months for appointments during buildup and then every 12 months at higher doses or during maintenance. What’s wonderful is the process is flexible in so many ways, and we will work with you to make the scheduling and travel as easy as possible for your situation.
Those who graduate from the main course of treatment (buildup and 1-2 years on maintenance) and choose to stay on SLIT treatment very long term to best maintain their progress can typically follow up once every 1-2 years if things are very stable.
Allergenuity Health is a direct care clinic which means we connect directly with you – our patient – for your care, and nobody else. We are able to provide care to anyone who desires our care, which necessitates that we not in-network with any insurance company. This means that we are paid directly by you for the care and services we provide you, and receive no reimbursement from insurance companies or the government. By standing outside the system, we are able to offer you many benefits that are highly desired but not offered in the standard insurance-managed system these days, such as ample appointment time with your physician to get your questions answered and build a relationship, direct access to your allergist without layers of middle-men, no outside interference in the medical decision making affecting your care, and so much more.
We have made every effort to make our pricing structure reflect the value of the services and quality of care we offer. If you have insurance and wish to use your insurance benefits, you may do so for most services that are not performed directly in our clinic (such as bloodwork and prescription medications). Please see the related question below.
Payment options: Our period of introductory payment options is coming to an end soon, so we will hopefully update this section accordingly when it does. For now, one option is simply to pay for the services you use at the time of service. We believe in price transparency in health care, so our current prices are transparently listed. Another option is to join one of the Allergenuity Health Programs we have diligently developed. These Programs are deferred payment plans that were designed to serve those who are committed and actively engaged in working with us towards their allergy health goals and who understand and accept that in order to benefit from immunotherapy, you have to commit to it for some time. Our deferred payment Programs provide you with all the main services you will likely need for a straightforward monthly fee, making your budgeting for care much easier and doing the same for our billing. This in turn allows us to give you even more value for what you spend on your care, since we can dedicate more time and effort to you rather than on optimizing our coding and billing practices. Being on a Program does not limit your medical care in any way. If an additional service is needed that is not listed under your Program, it is simply billed from our transparent list of Fees For Services. We developed these deferred payment Programs because we think they are a helpful option for all of us – to spread out the costs associated with pursuing a highly specialized care option such as what we offer – and to simplify the payment and billing process for us all.
We hope you find these options easy, fair, and convenient. The prices of our Programs and our Service Fees are all readily available here.
At Allergenuity Health, one of our missions is price transparency, so you can find our main prices listed here.
Another one of our goals is to have valuable, innovative, and personalized services, so we have done our best to make different options and price points available so that you can choose what is valuable to you for your specific goals and needs. If additional sublingual immunotherapy services are created specifically for you (such as an atypical product or a dose higher than the typical maintenance dose for a targeted allergen), we will determine the price of the specially-designed service at that time and will discuss it with you before you decide whether or not to move forward with that option.
Sublingual immunotherapy that uses FDA approved commercial antigen will be subject over time to market fluctuations in these antigen base costs. We have been told by our suppliers that there is typically an annual price increase of 8-15% each spring, and there can be other changes in prices depending on market demand or collection aspects. Obviously, no one likes price increases, us included, so we will do our best to keep your costs as stable and as reasonable as possible. We will continue to be upfront through the process if any price changes are necessary.
(Please note: the base cost of these FDA approved and regulated antigens is quite high, so if you are receiving SLIT drops somewhere for a very low cost or are purchasing generic allergy drops from a health store or the internet, keep in mind that you may not be receiving safe and regulated antigens, or you may be receiving them in very low doses.)
At Allergenuity Health, we want to make your entire healthcare process with us as easy as possible. One way we can make things easier is to take the frustrating, large, surprise medical bills out of the equation and help you be able to plan ahead to work your allergy health care expenses into your budget, just as you would your car payment, cell phone plan, or other important expenses. Another way we can make things easier is to provide you additional conveniences along with the best care we can.
Allergenuity Health Programs are deferred payment options we have developed to cover a set of commonly used services by paying a monthly fee. These Programs are designed for people who are truly committed to improving their health at the root cause of their issues and who are interested in pursuing the specific type of care and sublingual immunotherapy treatments we provide for the long term. We have structured our Programs to give you valuable medical services and many additional conveniences for a reasonable and stable price. Joining a Program is a commitment on both of our ends to actively work together for the next several years to attempt to retrain your immune system and improve your quality of life. By choosing the most appropriate Program for your healthcare needs, you will get a great value and access to several services and conveniences that are not typically available by medical clinics and physicians, and you will be able to spread out your payments over your entire treatment course (on average, 3-5 years). If you are a person who will be maintaining a SLIT treatment for the forseeable future, then after the initial buildup and 1-2 years on maintenance, if things are very stable, we will allow you to switch off of your Program payments and onto the Fee For Service regimen in which you can just pay for your treatment bottles and come in for a brief checkup and update every 1-2 years. Please see the details of our Program options here.
We don’t like paying registration fees for things so we won’t require that of you either. Therefore, there are no registration fees at Allergenuity Health. Rather than charge you up front to protect ourselves financially in case you choose to leave us, we are confident in the benefits and value of what we have to offer you and the fair way in which we have set up our reimbursement system. We hope you will find our upfront and straight-forward approach to the business part of health care refreshing.
At Allergenuity Health, we promise to always discuss appropriate initial and follow up testing strategies with you based on your unique situation and to only do those tests that aid in your diagnosis and treatment management. To stand behind this assertion with action, any commercial antigen environmental or food allergen skin tests that are appropriate for your initial diagnosis and follow up SLIT management are an included medical service for patients enrolled in one of our Programs. Fresh food skin tests require additional setup and steps and are not included in the Programs but the cost is transparently noted on our Fee Schedule. Requested but medically non-indicated skin tests will be considered and can be performed if appropriate for a specific reason (see Fee For Service schedule for those prices as well).
How do I get off of a Program that I have started at Allergenuity Health if I complete my treatment course or need to for another reason?
Depending on when and why you are leaving a Program with us, we have set up a few straight-forward paths to complete your Program and Program payments.
Graduates: Once you have completed the buildup and initial maintenance phases of your immunotherapy course, if you are feeling well and no longer requiring significant healthcare services, you will become a Program Graduate (congratulations!). If you are soon-to-be graduating from your Program, we will discuss the future care options available so you can choose which route will be most beneficial to you. If you will be completely discontinuing all immunotherapy treatment upon graduation to do a complete trial off of treatment, we will set the date for your final Program payment as appropriate per your treatment plan as we near that point. You can still use our services at any time via the Fee For Service payment model, including remaining on you maintenance sublingual immunotherapy doses for an extended or indefinite period. Alternatively, you can transition to a “Graduate Program” suited to your new specific needs (and at a much lower monthly expense) if you would like to continue to access the services and additional conveniences we offer on our Programs.
Long-time patients: If you have been on one of our Programs for more than 12 months and decide or need to stop pursuing our care services at Allergenuity Health for a reason other than Graduating from the Program, we ask for 2 months notice. The reason for this is that we do not require pre-payment for your services or included immunotherapy bottle(s) in order to allow you to have a more balanced cost deferment throughout your treatment course. Choosing or needing to terminate your Program commitment early can throw a wrinkle into our ability to sustain this system so we need to ask for your help in mitigating that by giving us a little bit of notice. Once we have that, we will work with you to determine the most appropriate end point for your services and payments within the upcoming 2 month period. We hope the pros to this Program system outweigh the cons, and we will transition you off both your treatment and your Program payment plan as smoothly as possible.
Newer patients: If you have been on a Program for less than 12 months when you decide or need to leave your Program commitment early, we will simply calculate the services you have used during your time with us using our Fee For Service price list. If that amount is higher than what you have already paid into your Program to date, the difference will be your balance owed. You can either pay your balance off at once to close your account, or you can maintain your Program’s payment plan installments (to spread out the payments needed to pay off your balance) with no additional services until your balance is $0.
Does Allergenuity Health file to insurance or accept any government or private insurance reimbursements?
No. In order to protect your ability for a deeper and more direct relationship with your allergist at Allergenuity Health – without middlemen, unnecessary delays, and numerous layers of interference in your medical management – we have needed to withdraw from the insurance-managed healthcare system completely and stand proudly outside of it. This means that now we are in a relationship directly with you, our patients, for your health care, and we hope that if you choose to seek care with us that you are as excited about this incredible freedom as we are. We can spend much more time with you, get to know you and your family better, and provide you with what we feel is the quality of personalized health care we all truly desire but has become so far removed from the norm in the “standard system”. Furthermore, if you want even more time or services from us, you can arrange for whatever you need and there are not even any surprise costs – our fees for whatever you desire for your care are transparently displayed on our website Service Fees section so that you can be fully informed at all times. We receive no reimbursement from insurance companies or the government at all, so we are paid directly by you for the care, medical services, and conveniences we offer that you value.
Can I get a superbill to submit to my private or government insurance for medical services at Allergenuity Health?
No. Unfortunately, providing you with a superbill to submit to your insurance for reimbursement would require Allergenuity Health to still somewhat operate within the insurance-driven healthcare system, which would mean losing our ability to protect a direct relationship with you and to offer you several other benefits and conveniences which we feel are far more valuable than any reimbursement amount you may (but likely would not) obtain. Superbills (invoices including all of our services with ICD-10 diagnosis codes and CPT codes) require a lot of invested time and money – to do trainings to attempt to keep up with the ever-changing and growing 70,000+ ICD Diagnosis codes and 10,000+ CPT codes, to hire a coding staff and billing staff to help advise on, modify, and manage the confusing coded bills, and to keep track of and document all your so-called applicable codes over time. Many times in the allergy field, we frustratingly do not even have an appropriate code for a particular situation (despite 80,000+ codes), so reimbursement becomes a battle or cannot even occur. By removing from our processes this complete waste of time and money that has nothing to do with your actual health care, we are able to put our resources into what matters most: your actual health care – spending more time with you, focusing on you as a person and not your codes and how they reimburse, and not wasting valuable time we could be devoting to you instead by battling with insurance companies over denied codes for no comprehensible reason.
We hope you feel the quality of care we provide to you more than makes up for the lack of being able to submit a superbill to your insurance company!
Yes. If you have private insurance or Medicare, you can use your insurance coverage and benefits for bloodwork and prescription medications if you desire. (We also offer very reasonable prompt pay rates if you’d like to pay for your bloodwork outside of your insurance through Allergenuity Health at a Labcorp center near you.) Due to specific state laws and restrictions, if you have NC Medicaid however, you cannot use your Medicaid coverage for anything connected with a non-enrolled physician (which includes us), but you can still choose to see us for care as long as you contract with us outside of your Medicaid coverage. If you have Medicaid from a different state, you will need to consult your Medicaid office for your state’s rules. Please let us know if we can be of any assistance.
Though we all want to use the health insurance coverage we have (and pay dearly for), it is important that we all remember that health insurance is not health care. We all have a choice in what types of health care to seek and which specific doctors to see, despite our health insurance coverage explanation often making us feel like we don’t. Our clinic offers several unique attributes that we hope will benefit those looking for more personalized, thorough, and comfortable care methods that reconnect patients and their doctors directly.
The answer here depends on which type of fund you have, which type of service you are looking to cover with that fund, and certain legal and employer-based eligibility issues. Since we are neither lawyers nor accountants, we do not want to misinterpret your current state laws or the current vague federal laws and risk potentially advising you incorrectly, so please consult your tax advisor to get the most appropriate and current advice on your specific funding situation and our clinic’s services. If you find out that you are eligible, we can set up to have your payments come directly from the account of your choosing.
If you would like to learn more about this topic, here are some resources that may be helpful:
IRS Publication 502 (for 2017 tax year)
IRS Code Section 213(d) – Eligible Expenses
IRS Code Section 223 – HDHPs and HSAs
We have worked very hard to make our pricing reasonable and sustainable for the type of service and direct care we provide, so the prices we have listed are our most discounted prices and are available for everyone.
Given that allergies tend to run in families, we also understand that multiple family members may want to seek our services simultaneously, and we want to do everything we can to make this as feasible as possible. Since some of the health education and counseling services will overlap for family members, we do offer the following additional savings for families (spouses and children under age 26) at Allergenuity Health:
2 family members: 10% Reduction in monthly Program payments or 10% Reduction in SLIT treatment fees
3+ family members: 15% Reduction in monthly Program payments or 15% Reduction in SLIT treatment fees
Basic Allergy-Immunology Topics
“Antigen” is a term for a substance that is capable of inducing an antibody immune response via signaling. Antigens can be molecules on the surface of viruses, bacteria, molds, pollens, foods, tissue cells (from animals, human donors, or even ourselves), and more.
Allergies are thought to arise out of a complex combination of genetic and environmental factors. These factors signal the immune system to produce the allergy antibody (IgE) upon exposure to a certain antigen (a pollen, food, animal dander, mold, etc), instead of classifying the antigen as harmless and ignoring it.
The IgE antibodies that are made by the immune system then find their way to “allergy cells” – such as a type of cell called a mast cell. Mast cells are found living in different body tissues (like the skin, nose, eyes, airways, stomach, etc) and can contain receptors that allow these IgE antibodies to bind to them. However, allergic reactions don’t occur just from the IgE antibodies binding to these allergy cells alone.
When the body is exposed to more allergen at a later time, the allergen particles can then find and bind to their previously made IgE antibodies that are waiting for them on allergy cells, and if enough of a load is present to bind enough IgE antibodies in a specific way (called cross-linking), the allergy cell then becomes activated. Activation of allergy cells releases natural chemicals like histamine that then go on to cause allergic reaction symptoms.
“Immunotherapy” is a process of prevention or treatment of a disease (such as an allergy, autoimmune disorder, or cancer) that involves signaling and modifying the immune system via mechanisms such as suppression, desensitization, stimulation, enhancement, down-regulation, and others.
For allergen immunotherapy, desensitizing and/or true tolerance-building effects (these are different) can occur in the short term due to early immune system modifications actively being directed by the sublingual immunotherapy signaling process.
Desensitization can be maintained in the long term by maintaining continued controlled allergen exposure (essentially continuing a form of immunotherapy indefinitely) such that the desensitized state is not allowed to come undone.
True tolerance can sometimes persist in the long term, often for a number of years after immunotherapy has been discontinued. This is due to more permanent immune system modifications that became established after having been maintained in a state of tolerance-promotion from immunotherapy for a long period of time. If tolerance begins to wane off of immunotherapy, it can be restarted for another (typically quicker) round to help re-modify the immune system, or it can be continued indefinitely to also maintain a desensitized state.
Immunotherapy offers the closest thing we currently have to a cure for allergies, but it is important to realize that it is not an absolute cure. Currently, there is no complete cure for any type of allergy or any other disease or condition that has at least a partially genetic basis. Though this is disappointing information, it definitely should not leave you without hope for the possibility of better control of your allergic conditions and an improved quality of life.
An allergic disease is a chronic medical condition with a complex genetic and environmental foundation. It can flare, be out of control, be under good control, or be in a type of “remission” state for some time, just like any other chronic disease. Though there is no complete cure, the right form of immunotherapy for you, along with integrative healthcare strategies that help reduce any other factors also aggravating your immune system, can get your allergic disease under very good control. This control is achieved and maintained while you are continually taking your immunotherapy treatment doses. For some people, based on multiple factors and circumstances, this control can then persist for a number of years off treatment as well.
This continued control of allergic disease while off of your immunotherapy regimen is considered being in a state of “sustained tolerance” to your allergies or “remission” of your chronic medical condition. During this time, it might feel like you are cured from your allergies, which is of course a fantastic feeling and should be embraced and enjoyed! However, for your safety and knowledge, it is always important to realize that even during a period of apparent sustained allergen tolerance, you are not guaranteed to not have a reaction upon exposure to your allergen(s), and it is not known exactly how long this remission or sustained tolerance will last. It is best to think of this “sustained tolerance” time as a gift of some time off of some form of immunotherapy treatment, not as a given for everyone after a treatment course, and not as a cure.
There are ways to give your immune system the best chance of maintaining your sustained tolerance and remission state as long as possible. Dr. Schroeder will review methods with you based on your specific situation when you reach this point in your treatment program.
Sublingual Immunotherapy (SLIT) Topics
What exactly is Liquid Antigen Sublingual Immunotherapy (sometimes also called “SLIT” or “allergy drops”)?
Sublingual immunotherapy (SLIT) is a safe process by which you and your allergist can work together to train your immune system to be more tolerant of your allergens. SLIT treatment engages special, tolerance-promoting immune cells underneath the tongue (the “sublingual” space) to influence and train the immune system to be more tolerant of allergens. These special cells, called oral Langerhans cells, are uniquely primed to suggest tolerance of substances they encounter, rather than an attack, presumably because they are the initial immune-system contact for our body’s vital nourishment substances – food and water. If these cells were primed to promote attack signals instead, we would not be able to survive. Therefore, the sublingual (under the tongue) method of immunotherapy harnesses the natural purpose of this very special type of tolerance-promoting cell in order to attempt to train or retrain your immune system to better tolerate harmless substances (allergens).
Oral Langerhans cells are a type of “messenger” immune cells found in the mouth. When engaged by substances they encounter, these oral Langerhans cells travel to the “decision-making” parts of the immune system (T and B cells) to share what they have encountered and suggest that the appropriate response is to choose tolerance rather than an attack. When a controlled, non-threatening amount of allergen is placed in the sublingual area of the mouth frequently and consistently (such as with long-term SLIT treatment), this creates a persistent tolerance-promoting signal to your immune system that can train (early in life) or retrain your immune system to respond more favorably towards allergen over time.
There are 2 forms of SLIT treatment available – liquid antigen (drops) and tablets. The SLIT tablets available currently each contain only one dose of one environmental allergen. This can be inconvenient and very expensive for those with multiple allergies, as well as too strong for some people, leading to significant side effects. Additionally, many environmental allergens are not available in tablet form, and no food allergens are available in tablet form.
The liquid antigen form – sometimes called “SLIT allergy drops” – is much more flexible, can treat for one or multiple allergens at once, can be adjusted to an extremely large spectrum of doses to fit your specific needs over time and increase its safety, and can be used for both environmental and food allergens. Liquid SLIT offers more individualized and comprehensive treatment than any other form of immunotherapy, which is a major reason we have chosen to use it as the primary form of immunotherapy at Allergenuity Health. This type of comprehensive SLIT treatment is best performed by an allergist with experience in formulating sublingual immunotherapy specifically, and at Allergenuity health, your SLIT treatment will be designed and managed entirely by Dr. Schroeder.
Anyone with known allergies or sensitivities (and related conditions that could include atopic dermatitis/eczema, asthma, hayfever, recurrent sinus infections, swollen itchy eyes, hives, stomach aches, fatigue, headaches, joint inflammation, food allergy reactions, anaphylaxis, etc) would likely benefit in some way from the retraining of their immune system in relation to a more tolerant approach towards allergens via a method like sublingual immunotherapy. Furthermore, those with known risk factors for potentially developing allergies (such as a strong family history of allergic conditions) could also benefit from training and guiding their immune system towards choosing tolerance of allergens early on before it gets too far off track. Whether or not to pursue SLIT treatment depends on a combination of factors involving the details of your allergic history and your specific goals.
There are many elements that affect an immune system and several different methods to attempt to train or retrain one, but liquid antigen sublingual immunotherapy (SLIT allergy drops) is a method that is overall regarded as safe and effective (when properly formulated and managed), flexible, and versatile. It is non-invasive and it can be used at any age, including infancy. It can often be safely used in conditions in which other forms of immunotherapy (allergy shots, oral immunotherapy) may be unsafe or contraindicated. Though like any form of immunotherapy it requires commitment and long-term use for best results, with SLIT there is overall much less time spent at a doctor’s office and away from school, work, or other parts of your life. After some time on treatment, many patients notice they require much less allergy (and even other) medication. If any of these features sound beneficial to you, you would likely be a great candidate for sublingual immunotherapy treatment.
Taking your sublingual immunotherapy allergy drops is easy. Open your mouth and lift up your tongue, and then fully depress the pump on your bottle to dispense your liquid allergens into your sublingual (under the tongue) space. If done correctly, you will notice a slightly sweet taste. Keep your tongue slightly up and let the liquid allergens rest in that spot for 2 minutes without swallowing in order to allow the immune cells in the sublingual area to notice and pick up the allergens from your treatment. (A decent amount of the allergens may be picked up within the first 30 seconds, so consider that the minimum but 2 minutes the goal.) When you’re done, swallow your saliva and whatever is remaining of the allergen unless advised by Dr. Schroeder otherwise, and go about with your day until your next dose! Your specific dosing parameters (the number of pumps to take at one time and the number of times per day to take them) will be discussed with you by Dr. Schroeder when your personalized treatment plan is designed.
Infants or young children may not be able to achieve this technique perfectly, but that is no reason to worry or hold off on treatment if appropriate. Dr. Schroeder will discuss alternate ways in which the allergy drops can be administered to little ones and still be effective at your appointment.
Yes. Sublingual immunotherapy (SLIT) drops can be adjusted to the right dose for each individual patient, making this an extremely safe form of controlled allergen exposure and immunotherapy. This is especially true when the treatment is designed and managed by a physician with appropriate proficiency in properly interpreting allergen testing (such as an allergist), and especially one who has significant experience in utilizing SLIT specifically.
Liquid antigen SLIT has been shown to be safer in general than allergy shots, oral immunotherapy (OIT), and SLIT tablets – resulting in less severe reactions with dosing than these 3 other forms of immunotherapy. There are several studies discussing and demonstrating the safety and efficacy of various methods of both environmental and food sublingual immunotherapy drops. Most importantly, epinephrine has not been required for adverse effects upon dosing.
Like with any form of immunotherapy, there are risks to be aware of, since an integral part of the treatment is controlled exposures to your allergens. A discussion of the risks and benefits of this treatment should be had with your allergist before starting.
Most patients’ experiences with sublingual immunotherapy (SLIT) drops is that they are easy to take and without significant side effects. However, like any treatment, there is a potential for adverse effects in certain circumstances, and it is important to be able to recognize them and know what to do. The most common side effects of SLIT are mild local reactions in the mouth such as tingling, a sensation of warmth, or itching. These symptoms tend to occur more often during the beginning of your treatment program or just after a dose increase during the buildup phase, and they tend to resolve within a couple minutes of a dose and stop occurring altogether within a few days or a week. For these symptoms, no medical intervention or dose adjustment is typically needed.
In patients with a history of eczema at any time, an eczema flare can also occur, especially at the initiation of treatment, during an illness, or during an updose. In the long run, SLIT treatment significantly helps control eczema, but it may also contribute to some (usually mild) flares, especially at the beginning, given the complexity of the eczema immunologic process.
Other adverse effects can occur but are more rare, and these can in theory be any type of allergic reaction since with immunotherapy treatment comes exposure to your allergens (albeit in a highly controlled way). Sneezing, increased mucus production in the nose and mouth, nasal congestion, mild asthma symptoms, hives, or a stomach ache have occasionally been reported in studies. Anaphylaxis is not a typical adverse effect concern with sublingual immunotherapy drops, especially when treatment is prescribed and managed by an allergist with the appropriate related skills and expertise and when using a long-term treatment method.
How long will it take to feel symptom relief after starting Sublingual Immunotherapy (SLIT allergy drops)?
Improvement in chronic allergen-related symptoms is typically seen well within the first year – as quickly as within the first few months for some individuals, but may take several months or closer to a year in others – so it is important to not be discouraged if quick changes are not seen and to hang in there. The immune system needs time to make changes, and this amount of time varies based on many factors that differ among individuals. Continued gradual improvement will occur over the next several months to years until you are feeling overall quite well compared to your starting point. An improvement in your quality of life is assured if you have the right condition(s) to be treated with this method, you are compliant with your treatment program, and your immune system is amenable to responding to this type of signaling and retraining. At Allergenuity Health, we will regularly connect to assess your progress and will use follow up testing as needed for additional information. Dr. Schroeder will make any adjustments needed to further optimize your treatment along the way.
Your results on Sublingual Immunotherapy will depend on several main factors, including your personal allergic history, your specific allergens and their unique properties, the complexity of your entire immunologic load, your overall health, lifestyle and dietary exposures, the design of your immunotherapy program, your compliance with your treatment program, the length of time you spend on treatment, and some factors internal to your immune system that we cannot test for or evaluate ahead of time and will observe as we are trying the treatment.
Some of these factors are controllable, and others are not. At Allergenuity Health, you can be assured that your sublingual immunotherapy program is designed and managed directly by Dr. Schroeder, a board-certified allergist with experience in utilizing sublingual immunotherapy to enact immunologic change, not an outside company. With your active participation in the treatment regimen designed specifically for you, you are sure to see some form of positive results. In the rare case that your immune system is resistant to this form of retraining, we will be able to tell within the first couple years and can discuss alternative options for you either with us or that may be available elsewhere.
The “short answer” is that your initial course of SLIT at Allergenuity Health will typically be designed for 4-5 years, including a build-up phase of 1-3 years and an initial maintenance phase of 1-2 years. That being said, there is significant variation from this due to many factors, and it is very important to have the correct understanding and expectations regarding what immunotherapy (of any kind) can do for you and how long you may benefit from treatment. If you’re interested in more information to better understand this topic, see the “long answer” below.
During SLIT treatment: The immune system is known to act based on a combination of signals from your genetic factors and your environmental exposures. Since we do not have control over genetic factors, we cannot change those fundamental signals your immune system is receiving. However, we can work together to provide as many tolerance-promoting environmental signals as we can, thereby training or retraining your immune system by educating it to look at its environment (including foods) more tolerantly. Most people begin to feel better and notice some protection from exposures when their immune system picks up on these non-threatening, controlled environmental signals. This is the allergy control and symptom relief you experience during the initial months to years on your SLIT treatment, for environmental or food allergens alike.
It can be tempting to stop your SLIT treatment earlier than recommended when you are feeling significant symptom relief, but the reason it is not recommended is that this usually leads to symptoms recurring fairly quickly once you have stopped since they were under control due to the allergen exposures and active signals coming from your SLIT treatment. Both the science behind immunotherapy and the clinical and research data collected over the past century strongly suggest that if your goal is to maximize your tolerance-building and potential for developing some sustained tolerance off of your treatment, you should remain on your treatment through your entire buildup phase and a 1-2 year maintenance phase.
After SLIT treatment: The longer your immune system continues to receive these favorable signals from your SLIT treatment, the more of a chance it has (and the more time it has) to actually break down the infrastructure needed to cause allergy symptoms and allergic reactions. This requires changes in more than just the amount of IgE produced, including changes in the numbers of certain cells in your body, the numbers of certain receptors on your allergy cells, and your immune system’s decision-making process when an allergen is encountered. For some people, if enough of this infrastructure is broken down and your genetic and environmental factors are also now cooperating with one another, a period of time off of SLIT treatment in which allergen tolerance persists can be possible. It is important to remember that this “sustained tolerance” time off of immunotherapy is not a guarantee for anyone on any form of immunotherapy (allergy shots, SLIT, OIT, etc), and it is not a cure. The way to have the most consistent symptom relief and allergen protection, as we currently know it, would be to continue on immunotherapy in order to always benefit from the controlled allergen exposures and active tolerance-promoting signals it provides.
Studies suggest that for environmental allergy-related conditions, the period of sustained tolerance off of either allergy shots or SLIT treatment is often at least 1-2 years. In our long-term SLIT experience, this can last much longer for some people. Similar studies for food allergies are lacking, but preliminary information, especially on rush or short-term food desensitization immunotherapy, has not commonly seen sustained tolerance after any form of immunotherapy treatment (OIT, SLIT, etc.) In our experience, however, periods of sustained tolerance for many food allergy-related conditions has been achievable for several individuals and appears to be more achievable the longer and more dedicated the course of SLIT up front.
What to expect: From over a century of trials, studies, and observation of patients on various forms of immunotherapy, it appears that at least 3-5 years committed to immune-training (signaling) treatment is important to have a decent chance at your immune system choosing to create more permanent tolerogenic changes during the process. These types of changes provide a form of long-term lasting effect (a period of sustained tolerance) without also needing the signaling method (immunotherapy) as well. Some data suggests that 4-5+ years on SLIT can be more beneficial than 3 or less years, with a longer up front time on SLIT leading to a longer period of sustained tolerance afterward. Some people may repeat another course of SLIT if their sustained tolerance begins to wane at some point, and there is good data that suggests a subsequent course can improve your symptoms and help you regain control of your allergies more quickly than the first. For some, perpetual SLIT treatment without time off may offer them the most protection and/or symptom relief, and this option can be a great and more natural long-term management strategy when compared to the other options such as chronic medication use to suppress symptoms or keeping up strict avoidance measures indefinitely.
Using all of these properties as we currently know them, your initial course of SLIT at Allergenuity Health will typically be designed for 4-5 years, including a build-up phase of 1-3 years and an initial maintenance phase of 1-2 years. Those with less allergens, less severe allergies, less risk factors, less chronic illness, or who have been on some form of immunotherapy before may be able to see benefit from a higher starting dose, a quicker buildup, and/or a shorter maintenance phase. Those with more complex issues may require a more gradual start, a slower buildup, and a longer maintenance phase to tolerate and benefit from the treatment. Dr. Schroeder will evaluate your individual factors and your goals and then design a sublingual immunotherapy treatment plan specifically for you. She will actively manage and adjust your treatment course while you are on it should circumstances change or your symptom control and test results suggest adjustments should be made in either direction. Therefore, your course on immunotherapy could be shorter or longer than someone else you know, or it could change at some point after you start, but you will always be informed about why it is what it is and will have direct input and communication with your allergist on the entire process.
How this works with our Programs: If you are on one of Allergenuity Health’s Programs, your Program length will cover your buildup period and at least the first year of your maintenance period. At some point after that, if you are doing well (which you hopefully are!) and are not requiring as many medical services and as much active management of your SLIT treatment as previously, we will discuss with you how to transition to your next phase – whether that is doing a trial off sublingual immunotherapy to assess for sustained tolerance, or it is remaining on SLIT for some time but switching to a Graduate Program or the Fees For Services system. All of these options will reduce your expenses while maintaining any immunotherapy or medical services with us that you specifically need or desire.
This can be answered in many different ways and at many different levels of detail. Here are 3 different types of answers to this question, depending on what you are looking for:
(1) The “short” answer, for those who just want the gist:
SLIT treatment engages special, tolerance-promoting immune cells in the mouth to attempt to influence and train the immune system to be more tolerant of allergens. These special cells are called oral Langerhans cells, and they are primed to suggest that the rest of the immune system choose tolerance of the substances they encounter, rather than an attack. This is presumably because they are the initial immune-system contact for our body’s vital nourishment substances – food and water – and if these cells were primed to promote attack signals like some other immune cells do, we would not be able to survive. The long-term, repetitive, slowly increasing but non-threatening exposures to allergens in this way over time begin to cause changes deeper with the immune system that can reduce the immune system’s ability and/or desire to react to exposures in the future.
(2) The “analogy” answer, for those who are interested in the overall concept:
Dr. Schroeder commonly tells patients to think of Sublingual Immunotherapy (SLIT) treatment as school for your immune system. Your immune system is the student, your SLIT allergen doses are the classes at school, and the tolerance-promoting signals your SLIT doses create for your immune system are the basic lessons being taught. The more frequently and consistently your immune system attends class (i.e. you take your SLIT doses), the more likely your immune system will begin to learn these basic lessons (i.e. to tolerate your allergens without over-reacting).
While your immune system continues to attend school (i.e. you continue on your SLIT treatment), the lessons grow and build on one another (i.e. your SLIT doses are adjusted and increase) until the main lesson (i.e. general allergen tolerance and an overall calm immune system) goes from initially having been an unknown concept to your immune system to now being a concept that is much more familiar and much better understood.
The longer your immune system continues to attend class (i.e. the longer you maintain your SLIT treatment), the more likely it is to potentially memorize the main lesson, thereby remembering it for some time after the course is completed (i.e. the more likely you may gain a period of sustained tolerance off treatment).
Many other factors also affect how well your “student immune system” learns the main lesson, such as whether or not there are stressors (i.e. major allergen exposures, illnesses, poor nutrition, lack of sleep, etc) interfering with your immune system’s ability to focus on learning this new lesson, whether classes (i.e. your SLIT doses) are regularly provided or are frequently canceled, and some additional factors outside of anyone’s control, such as whether your immune system innately learns quickly or slowly and whether it needs repetition to remember certain lessons or can memorize them.
There is generally a way to help any student learn and maintain the knowledge of an important or necessary lesson, though the route, method, and length of teaching time required will differ. Similarly, with allergy health, we can work together to find the way that works best for your immune system to learn the lessons you want it to learn.
(3) The more “technical” answer, for those who are interested in more of the medical processes:
The immune mechanisms involved in sublingual immunotherapy (SLIT), and any form of immunotherapy for that matter, are extremely complex. The full scope of this multifactorial process is not currently known, but several core mechanisms have been illuminated through study. There are some key differences between SLIT mechanisms and those of other forms of immunotherapy, such as allergy shots (SCIT) and oral immunotherapy (OIT), that suggest enhanced tolerance-promoting potential and broader immune-calming properties with SLIT.
In order to explain how SLIT can help improve your tolerance of allergens, it is first necessary to explain a little bit about how your immune system works and becomes allergic in the first place
When “messenger” immune cells (antigen-presenting cells such as dendritic cells, Langerhans cells, etc) encounter a substance in the skin, nose, stomach, etc, they process the substance, travel with it, and then share it and their suggestions about it with the “decision-making” immune cells (T and B cells). For example, if bacteria gets into a cut in the skin, the messenger immune cells in the skin will capture some of it to share with the decision-making cells and will suggest that this is an unexpected invader that needs to be removed. Next, these decision-making immune cells have to decide what they think they are looking at (a harmless substance, a piece of our own body, a virus particle, a bacterial particle, an allergen) and then how they want to respond. For the previous example, it would be recognized that the substance is a harmful bacteria, and then processes to kill the bacteria would be activated.
When the immune system decides to label a certain otherwise-harmless substance as an allergen, the B cells may go to work to “attack” it by producing something called IgE. IgE is an antibody that will bind to allergy cells to get them ready to react, and then help activate those allergy cells when the allergen is sufficiently present to bind to its IgE on those allergy cells – which causes an allergic reaction. Furthermore, these decision-making B cells also may create plasma cells that can “squat” in the body for years and just continue to mass-produce the specific IgE that can help activate allergic reactions. Additionally, the B cells can create memory B cells that can remember the earlier decision made about the substance previously encountered (that it is an allergen to be “attacked” with IgE), such that if the substance is encountered again, the “attack” response can be ramped up more quickly. These memory B cells can last years to decades. All of these layers and priming of pathways contribute to the intricate infrastructure the immune system creates over time to robustly react to allergens.
Here are the mechanisms we know of that are at play with Sublingual Immunotherapy (SLIT)
Sublingual immunotherapy uses special “messenger” immune cells in the mouth called oral Langerhans cells to capture the allergens in your treatment drops and provide tolerance-promoting signals to the “decision-making” part (T and B cells) of your immune system. These oral Langerhans cells are uniquely primed to suggest tolerance of substances they encounter, rather than an attack, presumably because they are the initial immune-system contact for our body’s vital nourishment substances – food and water. If these oral Langerhans cells were primed to promote attack signals instead, we would not be able to survive. Therefore, the sublingual (under the tongue) method of immunotherapy harnesses the natural purpose of this very special type of tolerance-promoting cell in order to attempt to train or retrain your entire immune system regarding harmless substances (allergens).
With consistent, long-term, non-overwhelming controlled allergen exposures (via SLIT), these oral Langerhans cells provide a persistent, wide-spread, tolerance-promoting influence to the immune system via their messages to T and B cells as well as the release of immune-calming natural chemicals. These natural chemicals are called cytokines, and each of them has a different effect, with some having the very important purpose of calming down the immune system. The previously built-up “attack-mode” infrastructure towards allergens (and sometimes even other inflammatory substances) begins to slowly come undone under this calming influence. If this “attack-mode” infrastructure hasn’t fully formed yet (such as with young children), these tolerance-promoting signals can help the immune system choose to change its course for the better before things get too bad (or get worse), which can remarkably prevent disease.
Once the immune system is in a tolerant state and the infrastructure to easily attack an allergen (or multiple allergens) has been broken down, the choice becomes whether or not to remain on the SLIT treatment that helped get you to this more tolerant state and may be maintaining you in it. For some people, if enough changes have settled in and if their outside influences (environment, diet, etc) do not seem like they would provide signals that would push their immune system back into attack-mode, a trial off SLIT would be appropriate. Many of these people find that they retain some or all of the benefit they were able to build while on the SLIT treatment for a prolonged period of time off of the treatment. For other people, their immune system may require the persistent calming influence of the oral Langerhans cells’ signals to keep their attack-mode immune infrastructure in check, otherwise it will start to rebuild. A longer or indefinite course on SLIT may be most beneficial to these individuals.
As the many gradual and intricate changes take place on SLIT treatment, tests like blood IgE and allergen skin tests each provide important information about one specific piece of the puzzle, but neither type of test will be able to provide enough information about the entire scope of changes that may be occurring at the time. Therefore, it is important to look at several factors including symptom relief, reactions to accidental exposures, and possibly multiple different types of test results in order to get as full of a context as possible about what may be occurring. There are some tests that have been used in research settings to measure the immune-calming chemicals released or evaluate portions of the infrastructure. However, these are not available in the clinical setting yet.
In many cases, the answer is “yes, typically for a number of years.” The right way to think about this topic is to remember that having an allergic condition or being prone to allergies is really a chronic medical condition, and chronic medical conditions typically require management of some form for a person’s entire life, usually by a combination of dietary, lifestyle, and medical management. Immunotherapy such as SLIT can be a great tool to add to these other methods in order to help control your chronic allergy condition(s), and it may even get you to the point where your control is maintained off of active treatment for some time.
Studies have shown that after 3-5 years of treatment with sublingual immunotherapy for environmental allergies, many people are able to stop their SLIT treatment (if desired) and maintain their results of improved symptom relief and allergen tolerance while off treatment for at least 1-2 years. This is called having a period of “sustained tolerance” due to the long-term effects of your SLIT treatment. A prolonged rather than rushed course on immunotherapy has been shown to be important to achieving this type of result, with some studies suggesting that immunotherapy treatment for 4-5+ years can lead to longer persistent results off of treatment later than immunotherapy done for 3 or less years. This is similar to the findings about the length of time some people experience persistent results after the standard 3-5 years of allergy shots (SCIT).
In our clinical experience, as well as in discussing with patients who had been on SLIT decades ago and allergists who have been providing SLIT for a long time, it appears that many people who have been on a long-term course of SLIT do have sustained benefit off of treatment for years and sometimes decades. So many factors play a role in exactly how this result may be for you, including factors that occur while you are off of your SLIT treatment, so there is no exact way to predict a length of sustained benefit ahead of time.
Restarting another course of SLIT treatment if needed down the road, due to a change in environment or return of symptoms, can often bring your immune system and allergy symptoms back under good control even more quickly than the first time. It can then again potentially provide you with even more years of sustained tolerance when cycled off of the treatment again (if desired). For those who notice benefit on their SLIT treatment but do not have a sustained tolerance period after stopping the treatment (due to other immune-related or environmental factors that cannot be changed), there is always the option of safely remaining on the treatment indefinitely.
Less has been formally studied about food allergy SLIT, but it makes sense that there would be some similarities to the results of environmental allergy SLIT discussed above in regards to the re-training of the immune system and possible sustained tolerance off of treatment. However, it also makes sense that there could be some differences, especially depending on the molecular properties of your specific food allergens, as well as based on other factors including your ingestion patterns. At Allergenuity Health, Dr. Schroeder will discuss with you the likely scenarios for you specifically, based on your personal allergy history and allergen details, and how your immune system appears to be handling your food SLIT treatment along the way.
Are there benefits to Sublingual Immunotherapy (SLIT allergy drops) that I can’t get from allergen avoidance or using medications?
Yes. Immunotherapy is currently the only medical intervention that can potentially change your natural course of allergic diseases. Sublingual immunotherapy has been shown to reduce the development of new allergies over time and to prevent or reduce the further progression of allergic diseases in all ages. In young children, a common progression of allergic disease is called the “atopic march” – typically beginning with eczema, then food allergies, then “hayfever” or allergic rhinitis, then asthma. Sublingual immunotherapy treatment offers the earliest and safest mode of intervention to attempt to train a young child’s immune system to follow a different course with potentially dramatically better long-term outcomes.
Sublingual Immunotherapy has also been shown repeatedly in studies about asthma and allergic rhinitis to reduce symptoms related to allergies to a similar or greater extent than medications alone. There is abundant additional clinical evidence of the benefits of properly-done SLIT treatments over avoidance or over medication treatments alone. SLIT can help improve stubborn atopic dermatitis (eczema), some causes of hives, various other rashes, certain chronic GI symptoms, tolerance to foods, several inflammation-related conditions including headaches, joint pain, sinus congestion, and more.
Additionally, there continues to be growing research and scientific evidence that strict avoidance of food allergens may contribute to the rise in food allergy prevalence and controlled exposures to these food allergens instead (as can be achieved with a method like SLIT) may provide the most potential protection.
What are the differences between Sublingual Immunotherapy (SLIT), Allergy Shots (SCIT), and Oral Immunotherapy (OIT)?
Allergenuity Health has chosen to provide comprehensive sublingual immunotherapy (SLIT) because it is the safest and most versatile type of disease-preventing and immune-modifying treatment currently available. Allergy shots (SCIT) and Oral Immunotherapy (OIT) also have benefits, but each has a limited scope and more risk to the patient without enough added benefit to outweigh the risks for most patients, in our opinion. Ideally, each patient would have access to each option and the best fit for your individual conditions and goals would be determined. Below is a more detailed comparison of SLIT, SCIT, and OIT so that you can think about which option may be best for you.
Sublingual immunotherapy (SLIT) has an abundance of study data and clinical evidence in support of its ability to train an immune system towards tolerance of both environmental and food allergens. Different than the other forms of immunotherapy, SLIT directly engages special immune cells in the mouth (oral Langerhans cells) that have demonstrated a preference for tolerance promotion. A reduction in medication use is generally seen over time on treatment, along with symptom relief, allergic disease improvement, and sometimes additional areas of health improvement due to the broader effects of general immune tolerance promotion. SLIT uses the FDA antigens approved for testing or injection but does not involve injections nor the pain and risks associated with that. It does not require weekly or monthly interruptions to your school or work schedule for doctor’s appointments as most of the treatment doses are taken at home. SLIT can be flexibly used to treat either one or multiple allergens at a time. It does not typically require an inconvenient rest period after each dose, and may or may not require decreasing your dose during an illness. It has a very low side effect risk profile, and anaphylaxis related to dosing is not a common concern. It can be safely used in patients with severe asthma and severe eczema with great results, though management by a physician with appropriate expertise is recommended. It is easy to do. Furthermore, SLIT drops can be used safely in pregnancy and in any age including infants and young children, which offers an incredible opportunity for allergic disease prevention. Treatment length greatly varies, but studies have shown that investing 4+ years on SLIT can not only improve your health and quality of life during treatment but can often lead to persistent results for years after treatment is stopped.
Allergy shot treatment (SCIT) has a century of evidence showing the benefits of immune modification by controlled allergen signaling. It is extremely effective at reducing the risk of anaphylaxis in those with severe venom allergy. This form of immunotherapy also uses FDA approved antigens. It typically requires weekly to monthly doctor’s appointments for injection administration and a 30 minute wait period for your safety. A reduction in medication use is generally seen over time on treatment. Injection immunotherapy is limited to only environmental allergen treatment after having proven very unsafe for food allergen treatment. There is a significant side effect risk profile including severe asthma exacerbations and anaphylaxis. It is contra-indicated in several severe allergic conditions and for patients on certain medications. It is not used in young children. In many offices, carrying 2 epinephrine auto-injectors with you for your shot appointments is required for your protection after you leave the office. Treatment length greatly varies but the average is 3-5 years on environmental allergy shots, often with persistent results for years after the treatment is stopped. Venom shots are typically carried out lifelong to maintain strong protection from potential anaphylaxis.
Oral Immunotherapy (OIT) is a newer option available in some clinics for the treatment of some food allergens. It has recently been the subject of several studies and significant research funding in the US. It is currently not FDA approved. It is typically limited to only one allergen at a time. It generally requires a long initial dose-escalation appointment and then weekly or every-2-week doctors appointments for further dose escalations. There is a significant side effect risk profile with in-office and home dosing including anaphylaxis. Having 2 epinephrine auto-injectors with you is highly advisable. A 1-2 hour activity rest period is usually required after each daily dose. Decreasing your dose is advisable during illnesses to prevent reactions. It is not used in young children. Protocols are generally set up to attempt to escalate dosages quickly to the point of tolerating a substantial amount of the allergen at a food challenge within 1-2 years, provided the dose escalations are tolerated. If the food challenge is passed, for continued protection, patients are generally advised to continue to eat a substantial amount of their allergen daily or on a regular basis, which for some is feasible and for others presents a big challenge.
The most studied treatment for venom anaphylaxis is subcutaneous immunotherapy (also known as SCIT or allergy shots). Venom immunotherapy by allergy shots has been shown in studies to reduce a person’s risk of anaphylaxis by 95%, which is by far the most successful result in allergy shots treatment to date. SLIT has not been as well studied with regard to improving venom allergy given the tremendous success of allergy shots in regards to venom-specific treatment, but there are some preliminary studies that suggest that there may be a role for SLIT in venom allergy treatment. However, at this time, our recommendation regarding treatment of venom allergy with immunotherapy is to use the subcutaneous (allergy shots) route.
Additionally, venom antigen has been undergoing a major shortage in the US recently and many patients needing treatment have had to go without. As such, we will initially not purchase venom antigen for diagnostic testing such that more is available for the clinics who use these antigens for allergy shots treatment as well.
Does Allergenuity Health treat chemical sensitivity with Sublingual Immunotherapy (SLIT allergy drops)?
Yes, but indirectly.
Chemical exposures are well-known to be irritating to your mucosal surfaces (the surface of your eyes, the inside of your nose, mouth, and GI tract, the airways in your lungs, etc). Putting chemicals in SLIT treatment – which contacts your mouth and GI tract – can be risky and may have unknown or unintended effects, so it is not something we recommend at this time.
Though it is plausible that a person may develop an allergy to a chemical, it is much more likely that symptoms related to chemical exposure are due to its irritating effects rather than an allergy. There are unfortunately no good tests to clearly determine whether or not a person is allergic to a chemical or has symptoms due to chemical irritation, though a detailed clinical history can help. Skin patch testing, often performed by dermatologists and some allergists, can provide very helpful information about which common chemicals may be bothering you and which you may want to avoid.
People who have underlying allergies and allergic inflammation of their mucosal surfaces may experience symptoms from a chemical exposure that seem out of proportion when compared to others around them. These symptoms may seem very similar to their allergy symptoms and may augment the process. Therefore, improving your allergy health will help heal your mucosal surfaces, which can help reduce your symptoms from many chemical exposures as well and return them to a more “normal” level. Therefore, at Allergenuity Health, we treat chemical sensitivity indirectly by using integrative health methods (including SLIT for your allergens) to reduce inflammation of your mucous membranes.
I have an autoimmune condition or an immunodeficiency. Can I still be treated for my allergies with Sublingual Immunotherapy (SLIT allergy drops)?
Yes. The immunotherapy practice guidelines note that immunotherapy can be considered in patients with autoimmune or immunodeficiency conditions, and we have used SLIT safely in patients with these conditions in the past. Furthermore, some patients with autoimmune conditions have noted an improvement in their autoimmune condition (psoriasis, thyroid disease, rheumatoid arthritis, etc) after starting their SLIT drops without any other changes being made to their autoimmune condition treatment regimen. This phenomenon has not been formally studied to our knowledge, but we do know that the tolerogenic mechanisms promoted by SLIT do function on both an allergen-specific tolerance-promoting level as well as a more broad immune-calming level, the latter of which could certainly help improve autoimmune conditions as well.
Yes. Sublingual immunotherapy has been used safely during pregnancy for decades. The safety of SLIT in pregnancy has been demonstrated both clinically and in studies. For example, a 6-year study assessing the safety of SLIT during pregnancy (published in the European Journal of Allergy and Clinical Immunology in 2012) actually found a lower incidence of morbidity and mortality in the 155 women on SLIT (and their fetuses) during pregnancy when compared to the general population or the medication use control groups. In 24 of these women, SLIT treatment had even been started during pregnancy instead of before. Their conclusion was that SLIT is safe to use during pregnancy and even to initiate during pregnancy.
If you are a new patient and become pregnant before your initial evaluation, please let us know as soon as possible so we can navigate the specific risks and benefits of starting SLIT during your pregnancy and choose the most appropriate route for your care together, whether that be delaying your testing and treatment until after your pregnancy, or making arrangements to cautiously start at an appropriate time.
Most current patients who are comfortably on SLIT when they become pregnant will not have to stop their treatment. If you are a current patient and may become or are pregnant, it is important for you to let us know right away so that Dr. Schroeder can review your SLIT treatment plan and make any necessary adjustments in order to keep you and your baby as safe and healthy as possible. Often as a safety measure as well as to help you best tolerate your SLIT doses without additional symptoms during pregnancy, we will maintain you at your current doses for the duration of your pregnancy and then reconvene any remaining dose advancements afterward.
Quite simply, liquid multi-allergen sublingual immunotherapy training is not part of the typical allergy fellowship training program curriculum in the US. As such, without instruction on and exposure to this treatment during an allergist’s formal training years, few allergists have experience formulating and managing this treatment, nor have they seen first-hand the many ways this form of sublingual immunotherapy can benefit patients. To obtain appropriate skills and experience with this treatment, an allergist would have to specifically seek additional training on his or her own.
Dr. Schroeder has a special interest in safely training the immune system to choose to handle allergens better and sought out experience with liquid multi-allergen SLIT after concluding her fellowship training. She has since treated close to 1000 patients with SLIT. At Allergenuity Health, we have chosen to make liquid multi-allergen sublingual immunotherapy our primary immunotherapy offering so that a high-quality SLIT treatment option that is managed directly by an experienced, board-certified allergist can be made available to anyone who could benefit from it.
As with any compounded, complex treatment, there is an extremely large variation in the quality of available treatments and treatment programs. Allergies are extremely prevalent, and patients, physicians, and companies are all searching for ways to treat these allergies. Given the overall safety of sublingual immunotherapy, several companies have started to provide compounding services for some type of “allergy drops” based on a variety of factors: some make a generic formulation that has no relationship to your specific allergies at all and that you can buy over the counter or on amazon.com, some use a protocol to formulate drops for you based on blood test results alone, and others may get some input from a physician who did some type of testing on you. These companies market either directly to consumers or they market to doctors as another treatment tool for their allergic patients. Some of these companies may use FDA approved antigens while others may not. Any dose-related information is usually hard to find and there is often concern about doses being too low, leading to less effective results.
Just as with any type of medical service or treatment, it is best to both do a little bit of your own research and also talk with a trusted physician who has a particular knowledge on the topic. Ask for some details about the sublingual immunotherapy treatment you are considering, who is managing it, where the antigens come from, how the dosing is decided, etc in order to make sure you are comfortable pursuing it from that particular place and to make sure you are getting the type and quality of treatment that you desire.
Briefly, SLIT allergy drops treatment is an off-label use of primarily FDA-approved antigens. This means that FDA regulations and safety standards are in effect for these antigens, but the antigens were originally approved for a different purpose (in this case, allergen skin testing and for environmental allergens, allergy shots).
Off-label treatments and procedures are completely legal and are prominent in good quality healthcare. In fact, without a physician’s ability to use his or her expertise and knowledge in a particular area to troubleshoot an issue for a patient and use or do something “off-label” that might help, many patients would unnecessarily have worse outcomes since no FDA-approved treatment can be standardized, studied, and subsequently approved for each appropriate disease in each appropriate age group or scenario. It often goes unrecognized that many pediatric treatments are actually off-label use of FDA-approved medications, for example. And that sometimes, off-label treatments are even safer and/or more effective than available FDA-approved treatments, or are listed as the “standard of care.” There has been a lot of confusion injected around the terms “FDA-approval” and “off-label use” leading to extremely inappropriate and dangerous interference by insurance companies and business administrators who incorrectly classify off-label usage as unsafe or ineffective and then deny patients coverage of important beneficial treatments recommended by their physicians based on this unfounded claim. Therefore, it is crucial that you as a patient understand the true meanings of these terms in order to best assess your own health care decisions and treatment options and in order to make your health care decisions in collaboration with your trusted physician.
The route of using the sublingual area of the mouth for allergen immunotherapy has also been approved by the FDA. There are now a growing number of FDA-approved single environmental-allergen SLIT tablets available. While these work well for some patients, especially those with mild-moderate seasonal allergies to only that one type of major allergen, many people find these tablets to be too strong for them and can experience short-term side effects or even long-term adverse effects stemming from too much allergen exposure in the GI tract. Additionally, these tablets only treat one type of allergen at a time, are currently only available for a few major environmental allergens, are expensive, do not treat food allergens, and are not suitable for young children. This leaves everyone with multiple significant allergies, young children, and/or food allergies still without a fully “FDA-approved” sublingual immunotherapy option and well-served by off-label sublingual use of FDA-regulated antigens.
Why is liquid allergen Sublingual Immunotherapy (SLIT allergy drops) treatment not typically covered by insurance in the US?
Insurance companies often take their cue regarding what they will need to cover to stay viable in the market from “FDA approved” treatments and protocols. This is a prohibitive misuse of this label and how proper healthcare works. Though off-label use of FDA approved treatments (such as liquid antigen sublingual immunotherapy) is not only legal but is counted on for physicians to be able to provide patients with the best individualized care possible, many off-label treatments are declined for coverage by insurance companies despite a qualified physician’s expertise and recommendation of the treatment. This is why you likely have experienced pushback from your insurance company when your doctor has recommended a specific treatment for you in the past, or had to go through a tedious prior approval process (most likely your doctor’s office did it for you), or had to switch to a different medication or treatment from the one your doctor recommended specifically for you at your insurance company’s demand if you wanted their coverage benefits.
It is important to know that an insurance company is not required to cover you for the most beneficial treatment for your specific situation. Many times, the most appropriate treatment for you may be an off-label use of an FDA approved treatment, which likely will not be covered by your insurance. Your option then is to make the sometimes tough financial choice about whether or not to go with your insurance company’s covered treatment or your doctor’s specific recommendation for you (or your desired treatment) and pay out of pocket. Sometimes it is not as difficult of a financial choice, especially if you have a high deductible plan and are paying out of pocket either way. You are not alone in this process, however, and can always ask your trusted physician for advice. She or he can help you weigh out the risks and benefits of each option so that you can make the best decision based on all the factors combined.
Yes. “Evidence-based medicine” is a term used in healthcare to describe medical decisions made based on demonstrable scientific proof versus medical decisions made based on theory or expert opinion (which are also important and necessary parts of good healthcare). As of 2013, there had been 77 randomized double-blind placebo-controlled trials investigating sublingual immunotherapy (SLIT), per the World Allergy Organization. There have been more studies since, as this form of treatment previously primarily used in Europe is gaining exposure and acceptance in the US.
These studies have repeatedly demonstrated the efficacy of both environmental and food allergen SLIT in symptom relief, disease reduction, and disease prevention. These results stem from short-term and long-term immune system modification and retraining. They have also demonstrated the safety of the sublingual immunotherapy method in general and in comparison to other forms of immunotherapy available such as allergy shots and oral immunotherapy. Studies looking at the unique immune cells found in the sublingual area of the mouth (oral Langerhans cells), in comparison with the immune cells found in the skin or elsewhere in the body, have reported that these oral Langerhans cells appear to have different properties when exposed to antigens – properties that promote tolerance generation and calming of the rest of the immune system rather than the typical activation response. All of this scientific evidence overwhelmingly supports SLIT as an important and appropriate evidence-based medicine treatment method for patients with allergic conditions.
At Allergenuity Health, we strongly promote the use of evidence-based medicine methods and also support science-based and common sense-based creative innovation. We recognize that “standardization studies” of immune system modifying treatments like sublingual immunotherapy are inherently limited because each person has unique immune system, genetic, and environmental factors, and furthermore has unique medical goals and needs. Therefore, we strongly support personalization of immunotherapy strategies, based on scientific principles, by those knowledgeable on the subject matter in order to optimize each patient’s care.