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Do you have a history of recurrent headaches (sinus pain and pressure, migraines); persistent nasal discharge or mucous with poor response to allergy medication and no response to antibiotics; did you have one or more surgical procedures on the nose and/or sinuses but symptom continue; do you develop itching “all over”, mostly at night; do you have a diagnosis of skin rash, eczema or urticaria; do you have a history of recurrent ear infections requiring multiple courses of antibiotics or even tubes?

If you said “yes” to any of the above, keep reading, as it is highly likely that you or your child have allergies

If any of the following situations apply to you or your child, it is likely related to allergies as it is not unusual for allergic conditions to go undiagnosed and even when diagnosed, often times immunotherapy treatments fail to offer good relief:

Allergy describes symptoms that occur when your body encounters certain substances in the surrounding environment.  These substances or particles, called allergens, will stimulate the immunological system. The result of such stimulation will be the production of symptoms. The mechanism that leads into production of symptoms is the allergic reaction.

When the symptoms develop in response to exposure to allergens floating in the air, it is called an inhalant allergy.

Inhalant allergens include dust, animal dander, mold and pollen.

Symptoms can occur also as a response to food allergens (in this case the allergen is ingested) or even as a response to touching an allergen or chemical substance (contactant allergy).

So, the concept of allergy implies a reactivity of your body’s immune system against something in the surrounding environment. The reaction triggers inflammation. The inflammatory molecules produce the symptoms when affecting the different organs of the body.  For the management of allergic conditions read You have allergies but medications do not help you enough and SLIT and LDA.

The proper management of allergic conditions

Allergy immunotherapy

Because allergy medication will not cure the allergic condition, patients interested in attaining a cure or significant reduction of their symptoms should consider Allergy Immunotherapy

Allergy immunotherapy consists of the administration of the same allergens that produce the symptoms. Usually, they are administered frequently in very small but increasing dosages, over a long period of time. The objective of the treatment is to lead to symptom-resolution and to attain long-term relief after treatment discontinuation. This type of treatment is the only one that can modify the reactivity of the immunological system so that the allergic condition disappears.

This treatment has the potential to cure allergies. It can be provided by injections (Injectable immunotherapy or “allergy shots”), by oral drops (because the drops are usually administered under the tongue, this modality is known as Sublingual Immunotherapy or SLIT), or by a modality that uses ultra-low doses of allergens (Low Dose Allergen Immunotherapy  or LDA). For more on Allergy and Immunotherapy see here .

Allergy vaccines are completely natural. They contain exactly the same allergens that you inhale, ingest or touch. Allergens are proteins, complex structures capable of stimulating the immunological system. These allergens are extracted from the pollen, mold, food etc., and once extracted, they are diluted in saline water, or in glycerin. When diluted in saline, a minimal amount of phenol is added, to prevent bacterial growth. Glycerin, another chemical very common in the food industry and a component of multiple household products. It acts as a preservative of the allergenic proteins so they do to deteriorate over time.

Allergy vaccines do not carry the type of preservatives that the usual vaccines do: heavy metals (mercury or aluminum), PEG, etc. They do not contain prednisone or any type of steroid. Steroids are frequently used for control of symptoms in acute circumstances. Sometimes these steroids are given as a shot (once or twice per year) and frequently called an “allergy shot”. Steroids are just a medication. Allergy vaccines do not contain steroids.

Sublingual immunotherapy (SLIT) refers to the administration of the allergy vaccine orally (inside the mouth), usually under the tongue. The drops are kept there for a certain amount of time and then swallowed.

As explained in the following paper, SLIT is not a new treatment modality. The oldest reference about SLIT dates back to the year 1900 when Dr. Curtis published his experience with SLIT.

Because of a series of mortality cases after allergy shots in England in 1986, the use of injectable immunotherapy all over Europe plummeted. That explains why SLIT is more commonly used in Europe but rarely used in the USA, even though SLIT was developed in the USA by the early allergy practitioners.

In this article, you will be able to learn about the historical perspective of SLIT development, and its advantages, namely safety and efficacy. SLIT is ideal for young children, the weak and the elderly patient, and for patients living far away from the doctor’s office.

SLIT has the unique characteristic of being very safe. To this date, no severe reaction has been reported following the administration of Sublingual Immunotherapy and there are no known cases of mortality.

Dr. Saporta has used SLIT for many years without any major problems. SLIT is absolutely safe to use in circumstances where shots are or could be contraindicated, like when treating the very young patient, the older patient, the patient on Beta-Blockers or the pregnant patient.

See:

^{Leatherman BD, Khalid A, Lee S et al. Dosing of sublingual immunotherapy for allergic rhinitis: evidence-based review with recommendations. Int Forum Allergy Rhinol. 2015 Sep;5(9):773-83. doi: 10.1002/alr.21561}

Asthma or asthmatic symptoms are very common.  Dr. Saporta’s experience is that with SLIT administration, the need for inhalers resolves quickly even in children. See here a report on the use of SLIT for the management of children with asthma

Asthma. Controversies in diagnosis and management

Asthma is a frequent condition, consisting in a reversible obstruction of the lower airway.

Lower airways include the breathing tubes called bronchi and other smaller tubes. These breathing tubes are surrounded by muscle that may constrict, producing obstruction and therefore difficulty breathing.

Asthma symptoms include cough, shortness of breath, sensation of chest tightness and wheezing. Administration of a bronchodilator medication leads to a resolution of the symptoms. The reason why bronchi may constrict is due to inflammation, usually triggered by exposure to an allergen (yes, asthma is an allergic problem), but also by exposure to non-allergenic triggers like smoke, other chemicals or physical factors like exertion, cold or humidity.

Bronchodilator medications: Albuterol is the bronchodilator usually used to alleviate the obstruction of the lower airways. Because it is used when the patient has symptoms, it is known as a “rescue medication. It can be administered by a nebulizer (usually used by young children) or by inhalers. The inhalers come with the name of Albuterol, Pro Air®, Ventolin® and others. There are also inhalers that are anti-inflammatory that are used as maintenance medications.

Despite this simple definition, an asthma diagnosis is elusive. Often patients with all the symptoms and using inhalers are told they do not have asthma. The situation complicates when patients have only 1 or a couple of the symptoms above detailed.

The term “Cough Variant Asthma” was coined to describe mostly children that cough during exertion, sometimes also with shortness of breath. This asthmatic cough responds to usual asthma medications, but because these patients do not wheeze, they are not called asthmatic.

The most important factor to be taken into consideration is that allergies trigger inflammation, which will lead into overproduction of mucous and hyperirritability of bronchial muscles leading into spasm (obstruction).

For the potential role of immunotherapy in the management of asthma see here .

Dr. Saporta has worked intensively on this issue and realized that the lower airway is very commonly involved (inflamed) in allergic conditions.

“Because of the obvious difficulties for the elderly to come to and from the office, they are often deprived of a treatment that otherwise could be very useful.

Due to a multitude of reasons, dust concentration usually increases in elderly homes. It is a common occurrence that seniors are reactive to dust mites. Diagnostic tests are often negative and symptoms may not be strongly suggestive of an allergic condition (as the person may only develop or more one of the following: persistent nasal obstruction, chronic cough, recurrent headaches, post nasal discharge).

These patients are often chronically tired, with poor mood and/or decreased ability to concentrate. These symptoms are easily dismissed (“expected at this age”). A program of home-based immunotherapy like SLIT appears to be ideal in this situation.

Oral vaccines are applied under the tongue. In Dr. Saporta’s protocol, they are held under the tongue for approximately 20-30 seconds and are then swallowed.

For the proper administration, a mirror should be used as it is impossible to properly count the number of drops by “feeling them drop” in the mouth.

When treating a very young child or a non-cooperative child, it is enough to apply the drops anywhere in the mouth. The sublingual mucosa appears to yield better results but the whole oral mucosa is immunologically competent.

SLIT (oral vaccines) are prepared by Dr. Saporta in the office. The composition of the drops is determined by the results of an allergy test.

Different tests can provide different results. The information of all tests can be combined to determine the formula of the oral vaccines.

In cases of clear reactivity but a negative test (example: exposure to cat or dog triggers asthma or skin rash, or any other clear symptoms) a formulation can be prepared even when the test is negative (non-reactive).

All this will be clearly explained at the office visit or during the internet-based encounter.

Because drops are mixed in Glycerin, the allergens will not deteriorate even after many months.  The contents of a SLIT bottle lasts a maximum of 6 weeks so for practical purpose a SLIT bottle will not expire before it has been used.

Again because of the stability provided by the glycerin there is no need for refrigeration, even though there is no problem in keeping the bottles refrigerated. On the other hand, it is strongly advised that the drops not be kept next to a window or in the glove compartment during hot days as heat can denature the protein, leading to a lack of efficacy.

The protocol designed by Dr. Saporta is very easy to understand, easy to follow and highly effective. Instructions are provided by Dr. Saporta and his assistant and in writing which make compliance easy to implement.

SLIT is not approved by the FDA. Its use is defined as an “off-label use of the allergenic extracts”. It is important to understand that approval by the FDA is not a requisite for a doctor to use a treatment modality. It only means that studies were not submitted to the FDA for its approval. Of note is that SLIT is used in Europe and not only it is approved by the European Medicines Agency (EMA) – the European equivalent of the FDA -, but it is also reimbursed by all health plans. In the US, insurance companies consider it an experimental treatment modality and therefore do not reimburse for it.

On the other hand, the pharmaceutical companies in conjunction with allergenic extract companies have produced allergy tablets also administered sublingually, with only 1-2 allergens and these tablets were approved by the FDA (for the significance of 1-2 allergens versus many allergens see here).

Reported reactions after SLIT administration include itching of the tongue or the lips, gastro-intestinal symptoms like nausea or vomiting, skin rash usually in the lip area or face and more rarely headaches. Dr. Saporta reviewed all problems occurring in his practice over a period of 5 years and no significant problem had developed. For the complete review of this topic, see here.

The characteristics of LDA are:

It is an injectable modality, but in young children, it can be administered orally. Injections appear to work better so they are the preferred method of administration.

Because it includes a very large number of allergens, not only inhalants but also foods, even chemicals and others, and because it does not require an allergy test, LDA is ideal for all allergy patients but of special interest for the very sick patients like the uncontrolled asthmatic, where testing or treatment can be dangerous, and the patient with severe skin rashes or food intolerance for whom usual allergy treatments do not provide any help.

It consists in the administration of ultralow doses of allergenic extracts. It literally reaches the level of dilutions found in homeopathies. At the time of administration, these ultra-low allergens are mixed with a natural enzyme called Beta-Glucuronidase.

LDA does not contain any type of preservatives.

After a variable period of time, the improvement starts lasting for 2 or more months. At that time, the interval between treatments starts to increase to once every 3 months, 4 months, etc. When interval between treatments reaches 1 year, the patient is advised to come once a year for 2-3 times and then as needed. Some people continue to receive a “booster” dose as needed, even at intervals of 2 to 3 years or even more.

Most allergic conditions can be helped by LDA. While the most common perception is that particles in the air (dust and pollen) can trigger allergic symptoms, the truth is that very commonly patients also develop symptoms by foods in their diet or by chemicals in their environment. It is very rare to find a patient that reacts to inhalant particles only. LDA has the unique characteristic of combining most allergens in the surrounding environment (inhalant allergens) with food allergens.

Treatment results are excellent. Dr. Saporta reviewed treatment results on patients on injectable immunotherapy versus patients on LDA and both treatment modalities appear to perform equally.

Some patients may require a 5-day course of Prednisone, starting 2 days before the treatment, primarily patients actively using inhalers. The prednisone will hopefully avoid the need for inhalers. Obviously if during those 5 days of avoidance the patient requires inhalers, by all means, the inhalers should be used.