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If you’re sniffling and sneezing, you’re not alone. Mild winters, like the one experienced in the eastern United States, can lead to longer allergy seasons because warmer temperatures cause some plants to produce more pollen.
For the millions of Americans who struggle with allergies, taking over-the-counter antihistamines, often combined with a steroid nasal spray, is enough to temporarily alleviate symptoms. But Abigail Bortnick, 41, wanted a way to prevent long-term allergic reactions.
“I had really bad seasonal allergies,” Bortnick says. Tests showed she was allergic to grasses and weeds, and she remembers feeling lousy when the pollen count increased. “I would have a runny nose, itchy eyes, everything,” says Bortnick, who lives in the Washington, DC area.
Allergy shots were an option, but with young children and busy careers, it was impractical to go to the doctor every week to get shots. So her allergist offered her an alternative, called sublingual immunotherapy, known as SLIT, a form of exposure therapy. She received liquid drops that she can administer herself. “I liked the idea of not having to do shots and being able to do it at home,” Bortnick said.
Five drops, personalized serum
The serum comes in a small bottle with a pump on top. Once a day, she puts five drops under her tongue. “It makes it easier,” says Bortnick. She can’t eat or drink for 30 minutes, so she aims to take them at the same time each day, so they don’t interfere with meals.
She started allergy drops a few years ago and saw significant improvement. “I have absolutely noticed that my allergies have improved a lot,” says Bortnick. She also noticed that she had more energy, possibly because she slept better due to less congestion and inflammation. When she starts a new bottle, she sometimes gets a “slight itch” in her mouth, but it quickly subsides. And at the height of grass pollen season, she is still taking Claritin, but her symptoms are much less severe.
Allergy injections and SLIT are both forms of allergy immunotherapy. Patients are exposed to very small amounts of the specific things they are allergic to in order to train the immune system to tolerate them, gradually, over time. Doctors make SLIT allergy drops the same way they make allergy shots, by mixing together extracts of allergens. For each patient, the serum is customized to include the specific blend of irritants that trigger their allergies.
“Part of the beauty of therapy is its convenience,” says Dr. Rachel Schreiber, an allergist in Rockville, Maryland, who treats Bortnick. Schreiber says patients typically remain on SLIT for several years. “We reassess each year to determine if we should continue therapy,” she explains. Sometimes patients stop too soon and symptoms may return. “It’s easy to start over,” in these cases, Schreiber says, and many of his patients improve over time.
There are two types of sublingual immunotherapy, liquid drops mixed by allergists that Bortnick takes, and dissolvable tablets, available for unique allergens. The Food and Drug Administration has approved four tablets, including one for ragweed, one for dust mites and two grass pollen allergy tablets, including one for timothy. The tablets melt within a minute or two after being placed under a person’s tongue. The American Academy of Allergy, Asthma and Immunology says the tablets have been shown to provide long-term improvement.
The most common side effects of the tablets are temporary itching or burning in the mouth, which usually goes away quickly. Studies show that the tablets have a good safety profile, although a serious allergic reaction is possible, so patients taking SLIT tablets are also prescribed an epinephrine auto-injector, known as ‘Epi-Pen. Typically, insurance covers the cost of these tablets.
“They’re very effective,” says Johns Hopkins allergist Dr. Howard Boltansky, but the main downside is that the SLIT tablets only target one allergen each. Since most people are allergic to several things, many patients prefer the gout option.
Boltansky has been practicing for over 35 years and recently began offering SLIT Allergy Drops. (He sees patients at Hopkins Ear, Nose and Throat Center in Lutherville, Maryland.) “The use of sublingual immunotherapy drops has increased due to the ability to include multiple allergens that are not available in the currently FDA-approved tablet,” Boltansky says. And, as patients learn about this option, they appreciate the flexibility and convenience, which also explains the increased interest, he says.
The downside is that SLIT Allergy Drops are not FDA approved, so they are not covered by most insurance, Medicare, or Medicaid.
Boltansky explains that when he makes the allergy drops, he uses the same FDA-approved extracts he uses to make allergy shots. The only difference is that instead of injecting the serum into a person’s arm, it is put into a dropper bottle, which the patient can administer at home. Thus, the drops are an “off-label” use of the extracts. “I’m completely comfortable with using FDA-approved allergy extracts in an ‘off-label’ fashion,” says Boltansky, pointing to an excellent safety record.
In Europe, many doctors have been using this approach for years, Boltansky says. And, just like with the SLIT tablet, doctors are also prescribing an Epi-Pen to patients taking the allergy drops, although he says serious allergic reactions are rare.
When a patient begins sublingual immunotherapy, exposure to allergens is very much controlled. “We start by giving people small amounts of what they’re allergic to,” says Boltansky. “As their body says it’s fine, we increase the dose a bit more,” he says. The drops are made from purified extracts, so Boltansky has a bottle of ragweed pollen, another for tree pollen, as well as extracts for dust mites and cats. So, if a person is allergic to these four substances, “we mix them in a personalized bottle of allergy drops,” he explains.
“When we start someone on immunotherapy, whether it’s drops or an injection, we initially approach it as a test,” says Boltansky. They try it for about six months, and if they’re fine, they continue the treatment. He says about 80% of patients respond well and treatment usually lasts 3 to 5 years.
Not all allergists offer SLIT Allergy Drops, given the “off label” status and lack of insurance coverage. “There is a wide range of effective and ineffective doses of SLIT liquid formulations,” according to the American Academy of Allergy, Asthma and Immunology. This is why people should find a doctor experienced in testing and formulating immunotherapy treatment, such as a board-certified allergist. Also, some board-certified otolaryngologists (ear, nose, and throat doctors, known as ENTs) have expertise in SLIT.
Abigail Bortnick pays around $600 a year out of pocket for her allergy drops. “I didn’t like that it wasn’t covered by insurance, but I thought the convenience factor outweighed the cost,” she says.
Boltansky says he would like to see more research to show how effective SLIT allergy drops are at preventing symptoms. “Hopefully over time, the studies will be done and the FDA will review them, and they will be approved,” Boltansky said. In the meantime, physicians will continue off-label use for patients who are good candidates for immunotherapy.