Sublingual immunotherapy: A new option for allergy patients - Veterinary Medicine
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Sublingual immunotherapy: A new option for allergy patients
Anecdotal evidence demonstrates that this needle-free method may also benefit patients with atopic dermatitis.


VETERINARY MEDICINE


ADVANTAGES AND DISADVANTAGES

One big advantage of SLIT is the ease of administration. Although many owners do not mind giving injections to their pets, most do not relish it and are happy to be presented with an alternative. Most dogs accept SLIT administration easily, even viewing it as a treat, which increases compliance. However, successful SLIT requires faithful daily administration, and owners with busy schedules may find it more convenient to give a less frequent injection.

Data from a supplier (including several thousand dogs) indicate that adverse reactions to allergy drops may occur in about 4% of dogs.9 Nearly all of these reactions are mild and temporary and almost never require cessation of treatment. Most occur soon after starting treatment but disappear within a few days or a week of continued treatment.

The most common reaction is transient worsening of clinical signs, usually increased pruritus. A few dogs may rub or scratch at their mouth after administration, perhaps analogous to the oral itch that some human SLIT patients experience. Occasional stomach upset or vomiting has been observed in a few dogs.

In people, anaphylactic reactions to SLIT are rare to nonexistent, and SLIT can be given to people with a history of reaction to allergy injections. In the experience at the University of Wisconsin's School of Veterinary Medicine, the same is true in dogs. We have safely treated numerous patients with SLIT that have had anaphylactic reactions to allergy injections.

PROTOCOLS FOR SLIT IN DOGS

Initial diagnostic and allergen testing

In general, do what you have always done. The process of diagnosing atopic dermatitis through diagnostic testing to eliminate other possibilities and follow-up allergy testing are the same whether you plan to treat with SLIT or allergy injections. Any combination of serologic or intradermal testing techniques may be used to establish the individual sensitivities of each patient.

Allergen selection and formulation


Table 1: Sublingual immunotherapy veterinary formulation suppliers
After careful testing, the principles for choosing the allergens in the prescription are exactly the same as those used when choosing allergens for injection ASIT mixtures. SLIT formulation suppliers (Table 1) are familiar with these principles and will provide a suggested formulation based on the allergy test results for each patient.

Dosing

Treatment involves a series of three bottles of escalating concentration. The allergen solution should remain in contact with the oral mucosa for as long as possible. People are instructed to hold the solution under their tongue for one minute before swallowing. Obviously, we cannot request the same of dogs, but it is important that the solution is dispensed directly into the oral cavity, not in food, and that the dogs refrain from eating or drinking for five to 10 minutes after the dose is given.

Multiple daily administrations are required for efficacy in people, and our clinical group strongly recommends that owners be counseled to administer the allergy drops twice daily, every day. If they forget to give a dose in the morning, they should give one in the afternoon and one before bed. This twice-daily dosing schedule is indefinite for the duration of therapy with no tapering. It should be mentioned that each SLIT formulation supplier has established its own protocol for allergen concentrations, dosing volumes, frequencies, and schedules; comparative studies of different protocols have not been performed.

It is easy to switch a patient from injections to drops. Three possible situations exist.

1. If the patient has had no response to allergy injections, I recommend the standard protocol, starting SLIT with the lowest-concentration bottle and escalating.

2. If the patient is stable and has been doing well with the injections (perhaps the owner is just tired of giving them), you can typically start directly with the maintenance vial of SLIT, with no need for the escalation phase.

3. If the patient is being switched to drops because of an adverse reaction to allergy injections, I recommend cautious administration of the lowest-concentration vial at first. If there seems to be any adverse reaction or worsening, reduce the concentration even further.

At this time, the ideal total duration of treatment is not known in dogs. In people, daily administration is continued for two to five years. After this time, if the patient is stable, treatment can be discontinued, and the effect appears to be permanent in nearly all cases. Whether that is true in dogs is unknown.

Follow-up evaluations

As with injection ASIT, it is important to re-evaluate patients receiving SLIT on a regular basis (e.g. after three, six, and 12 months of treatment, which is what we use in our clinical group). My subjective clinical impression is that response to SLIT often occurs quite rapidly—some dogs are improved three months after starting SLIT treatment, and most that will respond show at least some improvement, if not substantial improvement, after six months of treatment.

Adverse reactions

If any adverse reactions occur or persist, it may require lowering the allergen dose. You should contact the SLIT supplier for specific instructions as to how to accomplish this for that specific formulation.

CONCLUSION

There is much still to learn about this new allergy treatment. Even in human medicine, which has been using SLIT for more than 40 years, there is still debate about the optimal dosing schedule. I look forward to further studies in dogs that will provide additional evidence of efficacy based on controlled trials, will compare dosing regimens, and perhaps will compare this therapy more directly to ASIT administered by injection.

Editors' note: Dr. DeBoer is a consultant to Heska, manufacturer of Allercept Therapy Drops, but has no financial interest in any sublingual immunotherapy product.

Douglas J. DeBoer, DVM, DACVD Department of Medical Sciences School of Veterinary Medicine University of Wisconsin Madison, WI 53706


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Source: VETERINARY MEDICINE,
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