31.1 Looking for Unicorns

“I’ve never seen a patient only allergic to one thing. Why would you ever use (insert name of sublingual immunotherapy [SLIT] tablet here)?” The author uses sublingual tablets, however, this question is posed by many patients. Particularly in the United States, where the population is predominately polysensitized, finding a symptomatic monosensitized patient in an allergy clinic is probably like finding a unicorn, just not as exciting. The good news is that, while these tablets are great options for monosensitized patients, they work just as well for symptomatic relief in polysensitized patients. In fact, studies done for these tablets to obtain Food and Drug Administration (FDA) approval included polysensitized patients. While these tablets may not be the best option for all allergy patients, neither are shots. However, these tablets may be very good options for most of the patients and may even help bring in new patients to an allergy practice.

31.2 Who Is a Candidate for Sublingual Immunotherapy Tablet?

Anyone can be a candidate for immunotherapy. Anyone who has symptoms of allergic disease, positive allergy testing that correlates to their symptoms, does not have medical comorbidities which would reduce the chance of survival in the event of anaphylaxis, is not pregnant at initiation, does not have uncontrolled or poorly controlled asthma, and is not on any medications which would complicate treatment in the event of anaphylaxis. In addition, SLIT tablets should not be used in patients with eosinophilic esophagitis.

31.3 The Practical Applications of Tablets

There are groups of patients for whom tablet therapy works well. The following are examples of types of polysensitized patients where a SLIT tablet could be used:

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  “Fallen off the bandwagon” (FotB): Subcutaneous immunotherapy (SCIT) injection patients who have stopped coming in for their injections prior to completing a course of treatment. There’s a host of reasons why patients stop coming for injections, but regardless—if they have a history of symptoms and a positive test result to an antigen in one of the SLIT tablets, they are a candidate for this therapy. It may even help bring some of these patients back into the clinic. This has been discussed at the end of the chapter.

  
  
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  “Not able to do SCIT, can’t afford SLIT”: Some patients may not be able to fit weekly injections into their lifestyles for a multitude of reasons. In addition, many insurance companies don’t cover (non-tablet) SLIT, and some patients can’t afford the out-of-pocket costs. These tablets are generally covered under patients’ pharmacy benefits, can be done at home, and while the SLIT tablets may not cover all of patients’ relevant allergens, patients can still receive the benefits of immunotherapy by using them.

  
  
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  “Not here for 5”: The course of immunotherapy is generally 5 years. While no one can predict with certainty that they’ll be in a certain area for at least 5 years, some patients know for sure they won’t—military personnel, college students, some businesspersons, TV/print journalists, etc. These are just a few examples of patient groups that may move frequently or only be in particular location for a short time. However, that doesn’t mean they’re not candidates for immunotherapy. Sublingual immunotherapy tablets are easy to travel with and can be obtained nationwide. As long as it is anticipated that the patient will be in areas of the United States or in the world where the antigen that the SLIT tablet is treating is present in, then using a tablet is appropriate.

  
  
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  “The peaked polysensitized”: Polysensitized patients who either complain of symptoms in one season or have very mild symptoms at other times of the year, but have one season that causes them real problems. These patients are good candidate for ragweed or timothy grass SLIT tablets, if they have corresponding symptoms for the respective seasons and positive testing.

  
  
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  “The peakless polysensitized”: Polysensitized patients who complain of year-round symptoms either with no seasonal peaks, or very mild season symptoms. If significantly sensitized/symptomatic to house dust mites (HDM), these patients are good candidates for HDM tablet therapy.