Which personalized Allergy Treatment is right for you?
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Kara Wada, MD: Hello, welcome back to this episode of the Becoming Immune Confident podcast. My name is Dr. Kara Wada. I am a board certified pediatric and adult allergy immunology lifestyle medicine doc turned autoimmune patient.
Understanding Allergic Conditions and Allergy Testing
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Kara Wada, MD: Today, we are talking all about Personalized Allergy Treatments. These are conversations that I have every day when I am in clinic seeing my patients.
These patients likely are coming in to see me for their itchy, watery, red eyes, their runny noses, sneezing, congestion, frequent sinus infections, sore throat, that post nasal drip or that drainage that just keeps on going, cough, chest tightness, wheezing associated with asthma, and sometimes itchy rashes like hives and eczema.
When we think about treatment of these allergic conditions, we always fall back to our three pronged approach. The first and foremost, is how can we avoid those things that we are specifically allergic to or are triggering our symptoms? The way that we determine what those things are is through allergy testing.
So when we think about those symptoms that are bringing you in, we start by thinking about them in terms of inflammation. Inflammation is our body's response to infection, like a cold, to injury. Sinus surgery, or a bop on the nose, and insult. Insults include allergies, but they also include irritants, like smoke, perfume, barometric pressure changes, like those storm fronts coming through.
When we think about allergic inflammation, it's a particular flavor of inflammation, and it works like a lock and a key. So when we do allergy skin testing, we are applying or using those little locks, so a small amount of the particular allergen, to figure out if your body makes that specific key or that allergy protein, allergy antibody, that would say, "Yes, you are allergic to dust mite or you are allergic to birch tree."
We determine that by looking at those scratches and seeing if you've developed a red, itchy hive bump. And we compare that then to a little scratch we did with histamine. Histamine is the master key for the system, and it allows us to say, yes, we trust the results of this test. And when we compare your results to the various tree pollen, grass pollen, weed pollen, molds, and then the indoor allergens, we can then determine, yes, this is consistent with a positive for you.
Or no, this is consistent with a negative for you, which we compare to a salt water scratch. This process takes about 15 minutes or so, and we are able to have those results and discuss them in the office together. Alternatively, we also will sometimes do blood allergy testing. This specifically looks for those protein levels in the blood, and the advantage to this is that it doesn't require us to stop some of our antihistamine medications in order to get those answers.
The disadvantage takes a little longer for those results to come back, and we don't always check for the extent of things that we do with skin testing. So there's some nuance there.
Once we know what you're allergic to and we know your allergy profile, are you allergic or are you not? That helps them guide our recommendations moving forward.
Medication Treatments for Allergies
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Kara Wada, MD: When we think about, for instance, that next prong of treatment, which is medications, knowing whether you're allergic or not, and what those triggers are, may help frame our conversation around when we should start certain medications, and when we may be able to back off on our medication treatments.
We think about medications, the main purpose of these is to calm inflammation and help repair kind of those barriers or the lining of our respiratory tract, our nasal passageway, and our sinuses so that it is less reactive and responsive. We do this through oral antihistamine medications, things like Claritin, Allegra, Zyrtec.
More and more commonly, we use nasal spray medications. effective than those oral medications. So things like fluticasone or Azelastine, Flonase and Astapro. And occasionally we will use leukotriene based medications like Singulair. Increasingly for our patients who with very severe allergy conditions, we may use biologic or injectable type medications, which can be really game changers when it comes to turning down inflammation.
Immunotherapy: Allergy Shots
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Kara Wada, MD: The last piece of the puzzle is immunotherapy. So what immunotherapy does is it shifts our immune response from seeing those specific allergic triggers as the enemy or a problem, decreases our responsiveness to those specific triggers. And we can do this in three different ways.
When we think about allergy immunotherapy, you probably have heard about allergy shots.
And these are the mainstay of our type of immunotherapy that we offer. We think about allergy shots, it's also known as subcutaneous or under the skin immunotherapy. The shorthand for this is SCIT, S C I T. How does it work? We start with very small doses of specifically what you're allergic to, and we increase that dose over a series of visits. This is called your buildup. Once you reach your target dose or your maintenance dose, we then are able to start spacing out those visits from weekly out to once a month. This buildup process can occur in two different ways. We have a standard buildup, which typically takes somewhere around 40 weeks or so, so 6 to 9 months, or something called cluster buildup, where folks will come in to, in our office specifically, about 5 visits that are 2 hours long, and they will receive about 3 weeks of treatment during that 2 hour session.
Doing these cluster sessions allows us to skip some treatments and skip some doses. so that we are able to get up to that target dose within about 12 weeks time. Why is this important? We don't anticipate improvement in symptoms until we get up to that target or that maintenance dose. Some folks will experience symptom improvement before then, and we are really excited about that.
But we usually will say, let's give it a little time at maintenance before we say, "Am I one of the 75 percent of people or so who improve with allergy shots?"
Okay, so you've reached maintenance. Now, we want to continue this therapy for somewhere between three and five years in order to see lasting immune system change, meaning that once you stop shots, we would expect to see ongoing benefit, ongoing need for less medication over the long term.
All right. What are the risks though? So this sounds, sounds reasonable but what are the risks? But 1 in 200 folks will have a more significant allergic reaction to one of their shots. We always administer allergy shots within a supervised medical clinic, like our allergy clinic, where folks are trained to recognize and treat severe life threatening allergic reactions, anaphylaxis.
So we have EpiPens and all the other supportive medications and folks that are able to recognize and treat that present when we are giving shots. We also make sure to watch patients for 20 to 30 minutes after their shot. This is the highest risk time for those reactions. More common, folks will develop a, what we call a large local reaction.
This is essentially what you may see with a significant. Bee sting, so swelling, itching, redness at the site of the shot. These large local reactions do not increase the risk of a systemic reaction and typically improve within about a day or two time. We also will sometimes use antihistamine an extra dose of antihistamines if someone is having significant large local reactions.
We want folks to continue taking an antihistamine on the day of their shots, continuing through that three to five year process. But as people are improving in their symptom control, we are working on backing off on medications as symptoms will allow.
All right, so maybe allergy shots in those weekly visits sound a bit daunting.
And you want to consider some of the other forms of immunotherapy. I will at least mention, so allergy shots are considered FDA approved. So they are approved by the federal food and drug administration. And vast majority of the time they are covered. to some degree by commercial and public insurance plans.
It is important to check with your insurance company to see how well allergy shots are covered. To what extent will they cover the cost of your shop visits and the vials. So there are two parts to that. So you can ask the office to get the codes that they bill for, in order to talk with your insurance company about that.
Our other two types of immunotherapy, we're going to start talking about some which are considered off label from the FDA. This means that they very well may not be covered by your insurance and would have to be paid for out of pocket. or using something like a flexible spending or health spending account.
Immunotherapy: Sublingual Immunotherapy
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Kara Wada, MD: So the second type of immunotherapy is called sublingual or under the tongue immunotherapy. These are more commonly called allergy drops or sublingual immunotherapy tablets. So there are currently three tablets that are FDA approved that treat allergies. Over this three to five year period of time, similar to allergy shots.
Those tablets are available for grass allergy, like the northern pasture grasses. These are like Kentucky bluegrass, Timothy grass that are present through most of the United States. Ragweed, which is a very common fall allergen, and also dust mite. Now, if you are allergic to quite a few things or to cats, dogs, those that are not available in tablet form.
Some offices, like mine, will offer something called allergy drops. We use the same ingredients we would use to mix someone's allergy shots. But in a little different concentration and formulation than we would inject. So these are then available to administer under the tongue. So logistically, how does this work?
Patients will start their treatment in the allergy office during a 20 minute supervised visit where they will take their first dose. We'll go through the process of how that will proceed. And we also talk to them about how to use an epinephrine pen if they would need it.
Now, the chance of needing to use an EpiPen with sublingual immunotherapy is much lower than that of our patients with allergy shots, which is why we're able to allow folks to use this treatment at home. But there is still a small risk, so we like to cover our bases, make sure we are really doing everything we can to keep everyone safe.
The biggest side effects we see with sublingual immunotherapy are itching under the tongue, mild swelling in the mouth, throat irritation, itching in the roof of our mouth, or sometimes itching in the ears. This tends to get better as folks continue on treatment. Less common, but still need to mention there are some cases of people developing difficulty swallowing or increased heartburn or reflux that has been related to something called eosinophilic esophagitis.
This is not common, but this can happen as a result of sublingual immunotherapy. So if someone were to experience that after starting this treatment, we would want to know about it. So that would be a reason to contact your allergist or whoever is prescribing that treatment. Typically these treatments are continued on a daily basis for that total of three to five years in order to see that potential for a lasting benefit once you stop treatment.
With sublingual immunotherapy, often we will choose to treat for those allergens that are the most problematic as opposed to treating for absolutely everything. With shots, we tend to include everything and then the kitchen sink in the formulation. With allergy drops, we will limit that to the things that we think are most problematic in order to make sure we are affecting the best.
we can with those particular allergen triggers. By treating those most prominent allergies, we are still turning down the volume on the overall, excess of that allergic flavor of inflammation. With allergy drops or tablets, we would expect to see some benefits or symptom improvement around the 12 week mark, 3 month mark.
I typically will tell patients give it 3 6 months. To say, is this really helpful? Is it moving the dial? Is the juice worth the squeeze? Or should we think about a different treatment strategy?
Immunotherapy: Intralymphatic Immunotherapy
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Kara Wada, MD: The last form of immunotherapy is the newest kid on the block. And I have to say it is the one that I am pretty excited about.
It's called Intralymphatic Immunotherapy. So let's break that down. Intra means in, lymphatic means lymph node. So we are essentially injecting a very small amount of the allergens that are most pertinent to your profile. using ultrasound guidance directly into a lymph node. You're like, "Oh gosh, what does that mean?"
So we use a little ultrasound device to find a lymph node, which is anywhere from the size of a raisin to an olive. And we do that in your inguinal area. So that area where your leg meets your body. You can feel those big blood vessels there. We move away from those and find a great lymph node to target.
We then inject a very small amount of those allergens specific for you at day zero, at four weeks, and at eight weeks. And that's it. We anticipate seeing symptom benefit around the 12 week mark. And the other main advantage to obviously three visits compared to dozens of visits with subcutaneous or traditional allergy shots is that in the lymph nodes, we do not have the cells that create anaphylaxis.
On the needle's way into that lymph node, there are a few of those allergy cells, right? So there is still a small risk of reaction, but overall the risk of reaction is much lower than what we see in traditional allergy shots. Additionally this really speeds up the process, makes it a whole lot more convenient.
There is even when you think about less waste and less impact on our planet, we think about all the syringes and gloves and different things we use over the course of three to five years of treatment compared to three relatively quick visits is really incredible.
The hope is that this treatment may eventually pan out to be helpful for allergies aside from those that are just affecting our eyes, our nose, and our respiratory tract. So currently we are just using this treatment strategy to treat for kind of regular seasonal and year round allergies.
But the hope is that with further research this may be a viable option for people who have Stinging insect, like bee sting allergies, and potentially for food allergies.
These areas are still under research and in the meantime, continuing to gather experience with this technique in treating seasonal and year round allergies.
Now, the disadvantage to this, you know similar to sublingual immunotherapy, is that it is not covered by insurance. That being said, the overall cost when we look at co pays, our time, going to and from the office, for many people, they may see this as a really great option for them.
Choosing the Right Allergy Treatment
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Kara Wada, MD: So as you are thinking about your allergy tests, getting kind of these results, moving forward and formulating a plan with your allergy immunology doc.
These are all things to think about and to ask about at your next visit to consider what might be the best personalized approach for you. How much is going to include Avoidance of allergens, how much medication and what medications are right for you, based on your experience and side effects and other health conditions.
And then is immunotherapy something you want to consider? And if so, what type fits best with you, your time, your energy? And your budget.
Conclusion and Additional Resources
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Kara Wada, MD: So I hope this was very helpful. If you want to learn more we have a prior episode we will link to in the show notes that covers all about intralymphatic and sublingual immunotherapy.
So we will link to that. And we have another episode tackling talking all about non allergic rhinitis. So when those allergy tests are negative, what the heck does that mean? And so we will link to that as well. I hope you found this helpful and stay tuned for an exciting episode next week and we'll talk again soon.
If you are loving this mix of self discovery and science found here on the Becoming Immune Confident Podcast, I'd love to invite you to sign up for my email list. Hop over to drkarawada.com and hit subscribe to ensure you don't miss out on any insights into new immune system science or how we can harness healing through our daily habits.
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