Discover the benefits of immunotherapy for chronic allergies in this informative blog. Dr. Adam Weisstuch explains common allergens and delves into treatment options, including the pros and cons of allergy shots versus drops.
Shelby Stockton (00:00):
Welcome to the South Florida ENT Audio Blog. I'm your host, Shelby Stockton, and today I spoke with otolaryngologist Dr. Adam Weisstuch about immunotherapy. Dr. Weisstuch talks about common allergens and treatment options, including the pros and cons of allergy shots versus allergy drops. If you suffer from chronic allergies, take a listen to the podcast to find out what treatment may work best for you.
Hi, Dr. Weisstuch. It's so nice to have you with me here today.
Dr. Adam Weisstuch (00:27):
Hi, how are you? Good to see you again.
Shelby Stockton (00:30):
Yes, you as well. So today I have a lot of questions for you about immunotherapy, and I would like to start though with what are inhalant allergies and how common are they in the United States?
Dr. Adam Weisstuch (00:44):
So inhalant allergies or simpler to see them as environmental allergies are the allergies that create changes in patients and reactions based on their environment, meaning whether it's molds or trees or weeds or pets or something like that. So more environmental allergies that affect different patients in different ways.
Shelby Stockton (01:12):
And are they super common in the United States?
Dr. Adam Weisstuch (01:16):
Yes, very common, but some patients have mild findings or symptoms and some patients have severe and everything in between. There's plenty of patients that walk around and even though they have allergies, they're not really affected by them, or they are more affected or less affected depending on what environment they're in. And then there's other patients that are almost debilitated by their allergies.
Shelby Stockton (01:41):
What are some treatment options?
Dr. Adam Weisstuch (01:44):
So there's a treatment ladder for allergies. And again, depending on how bad the symptoms are, we generally start with environmental control. So, if we find that a patient is allergic to a specific class of allergens, whether they be indoor, outdoor grass, weed, if we're able to help the patient and coach them about controlling their exposures, then that's ideal and sometimes simple.
When that becomes more complicated or impossible or still doesn't work for the patient, we talk about medical management for them, whether that be certain simple over the counter meds or even prescription meds like antihistamines and steroids. Then that's the next step in the latter. And sometimes patients do a little bit of both. After that, there are more involved therapies that can try to aim or treat for cure, not to “bandaid.”
Shelby Stockton (02:44):
Can you tell me about allergen immunotherapy and how it works?
Dr. Adam Weisstuch (02:49):
Yeah. So allergen immunotherapy is the next step on the ladder. It's where we find out what a patient is specifically allergic to and then we come with a treatment plan specific for those allergies where what we're doing is we're taking the allergens they are reacting to in small but safe doses and introducing it to their body in regular intervals. So essentially we're teaching their body to get used to the thing they're overreacting to.
So, for example, if a patient was allergic primarily to dust mites, we would use dust mite allergen in small safe doses in regular amounts, and essentially over time allow their body to acclimate to it. And that can be done for a number of environmental allergens individually or together.
Shelby Stockton (03:44):
Can you explain what is subcutaneous immunotherapy, also called SCIT, and what is sublingual immunotherapy, also called SLIT?
Dr. Adam Weisstuch (03:55):
Yes. So subcutaneous immunotherapy or SCIT is what a lot of patients see as this additional immunotherapy, where patient comes into the office and they will get a shot or two which contains the allergens they're allergic to in, again, those safe and central doses. And each shot as they progress has a slightly higher dose until they reach what we call maintenance, where they're at the highest dose or a concentrated dose.
And then once they reach maintenance, assuming they're doing well, we then start spreading out the intervals between their shots, so they come less often. That's done in the office under the guidance and management of biology technicians and our physicians.
And then sublingual immunotherapy, which is also called SLIT, is where we take a different concentration and formula of that allergen with the same concept, and we put it in a vial where the patient can administer the dose on their own at home under their tongue. That's why it's called sublingual. Because of the delivery method, it's safer and therefore it's allowed to be done at home after a patient is trained in the office and monitored and watched.
So, from a convenience perspective, it's far easier for a patient, but it's the same treatment concept. It's more convenient because the patients don't have to come into the office. But depending on insurances, sometimes it's more expensive because subcutaneous has better insurance coverage.
Shelby Stockton (05:40):
What are the risks associated with allergy shots versus allergy drops?
Dr. Adam Weisstuch (05:45):
So the general or worst risk that can happen is an anaphylactic reaction, which if done right is extremely rare. And with shots, that risk is present because of the amount of allergen in the shot and the delivery method, and that's why it's done in the office. At the same time, we have countless protocols in place to, A, avoid that risk, minimize that risk with how we test our allergens, the concentration in how we deliver them to patients.
And then we also have if and when something happens, we have the ability to treat it. That's why it's done in the office with the doctor. That risk for allergy drops is, as I just said, it's low with shots. It's ridiculously low with drops, and that's why we allow the patients to do it at home. The other risks, small risks, are you can get a little swelling around the injection site.
Same thing with drops. You can get a little tingling under your tongue, but those are the main risks to talk about with patients. And then as far as how well or how fast the treatment can work with them, that's different for each patient.
Shelby Stockton (06:59):
So, what percentage of patients in your practice are doing shots versus drops?
Dr. Adam Weisstuch (07:05):
I think in my practice it's about one-third drops, two-thirds shots, and generally the drops patients are the patients who for their time, effort, and finances, it makes sense for them not to be coming to the office often, or they travel a lot. A lot of the pediatric patients will do that because for parents to get a kid in and out of school. So it's about one-third SLIT, two-thirds SCIT. And I see that number has gone up year after year after year, especially as deductibles and copays go up as well. It makes the delta between the two treatment options smaller and smaller.
Shelby Stockton (07:55):
What is the ideal timeframe for treatment with immunotherapy?
Dr. Adam Weisstuch (08:00):
In a perfect world, we're treating a patient for at least three to four years. That doesn't mean that they're coming in all the time. For drops, because they're doing it at home, the inconvenience is minimal. The reason to do either of the treatments for that long is because you get the patient better and in a good place. They'll have improvement in a few months, and they should have real good symptom control or resolution of their symptoms in nine months to a year. But maintenance is the most important factor.
Because if you don't maintain them at a certain dose for a certain period of time, they relapse. And that's why the treatment is for so long. So with drops, the treatment just continues. With shots, as you escalate the dose towards the maintenance that I referenced earlier, you start spreading out the shots. So a crude way of looking at it is if you're doing three to four years, each year you're spreading out your visits another week, so meaning once a week, then once every two weeks, once every three weeks, once every month.
At the same time, we understand that patients can't necessarily make it all the time for a treatment that's that intense. If you miss a shot here and there, it won't affect your treatment and it won't affect your outcomes. So if a patient has a vacation or they're ill or they have to travel for something and they miss one or two shots here and there, that's not a problem at all.
The problem starts when a patient is missing three or four appointments in a row, and then the question is, do we have to step them back to step them forward? So we try to make it as convenient as possible. But the longer the patient stays in based on our recommendations, the better they'll have long-term relief.
Shelby Stockton (09:51):
So it's quite a commitment, but well worth it for people that are debilitated by allergies, right?
Dr. Adam Weisstuch (09:58):
Yes. If you have the right patient and you set them up with the right protocol, they're very happy.
Shelby Stockton (10:03):
Well, doctor, I appreciate your time. Thank you so much on educating us more about immunotherapy.
Dr. Adam Weisstuch (10:09):
Thank you.
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