Understanding Sublingual Immunotherapy

Allergen immunotherapy, also known as hypo-sensitization, desensitization or allergy vaccination, is a form of long-term treatment that decreases hypersensitivity to allergens and related symptoms for many people with allergic conditions like food allergy. The science of food allergy immunotherapy is progressing in the direction of desensitization for food and food immunotherapy is now available as food SLIT (Sublingual) or food OIT (Oral Immunotherapy) for various foods for patients with IgE-mediated food allergies.

What is Food SLIT?

The current standard of care for food allergy is avoidance and carrying emergency medications for accidental reactions. More and more patients are seeking treatment options for food allergies to reduce the risk of severe allergic reactions due from accidental exposure to food allergens. The currently available treatment options that are new but not widely accepted include food SLIT (Sublingual) or food OIT (Oral Immunotherapy) for various foods.

The Food SLIT involves administering patient-speciﬁc food allergen preparations under the tongue, holding it in your mouth, and then swallowing, once a day. We will have a patient-speciﬁc schedule to follow, starting at a safe, low concentration and increasing gradually to achieve some level of desensitization for a particular food or foods. Doses of these allergen mixtures will be started in the oﬃce and increased over a short period of time until a maintenance dose is reached. Daily therapy is administered at home after the ﬁrst dose of each bottle in the office.

Young boys undergoing sublingual immunotherapy

What is the goal of this process?

The number one goal is safety. The ﬁrst objective is to reduce the risk of a severe allergic reaction, from accidental cross-contamination of food. The long-term objective is to allow the patient immune system to become less reactive to foods that contain allergenic food by desensitizing the immune cells.

What are the phases? - Sublingual Immunotherapy has two phases

Build-up phase: This involves receiving SLIT drops with increasing amounts of the common food allergens once daily. The length of this phase depends upon how often the number of food allergens is administered and the patient’s ability to tolerate the doses. It can last from six months to one year.

Maintenance phase: This begins once the eﬀective dose is reached. The eﬀective maintenance dose depends on your level of allergen sensitivity and the patient’s response to the build-up phase. During the maintenance phase, the daily dose is kept the same and continued for an additional 1-3 years. We will continue or stop food SLIT based on ongoing monitoring and discussion with you. Many patients on food SLIT may transition to food OIT before or during maintenance. The initial studies suggest that the patients on food SLIT have an easier transition to food OIT and may tolerate food OIT better with fewer side eﬀects. Some patients may not require food OIT if the food sIgE drops signiﬁcantly during the food SLIT.

What are the possible Risks of SLIT?

The majority of patients do not experience any symptoms. In a small number of patients, a mild itchy mouth or tongue may occur. It is usually self-limiting and goes away without any treatment in a few minutes. Though severe reaction is very uncommon, in some instances, symptoms can include increased allergy symptoms such as sneezing, nasal congestion mild swelling, or hives. Severe reactions to food SLIT are rare but include the possibility of anaphylaxis.

The signs and symptoms of anaphylaxis include trouble breathing, wheezing or tightness in the chest, hives or swelling, tightness of the throat, hoarse voice, nausea, vomiting, abdominal pain, diarrhea, dizziness, fainting, low blood pressure, rapid heart beat, a feeling of doom, cardiac arrest. It is necessary to have adult supervision for 30 minutes after administering the food SLIT dose. We advise you to have access to emergency medications, including an epinephrine auto-injector and antihistamines.

Where should food SLIT be started?

This type of treatment should be supervised by a specialized medical provider in a facility trained with proper staﬀ to manage adverse allergic reactions, if any should arise during the food SLIT. Ideally, the ﬁrst dose of every new food SLIT bottle should be given in our oﬃce.

Should routine allergy medications be stopped before the ﬁrst-day procedure?

No. Patients should take all routine medications as they normally would and be allowed throughout the SLIT.

What is the timeline for the months after the ﬁrst day?

Exactly how it will go depends on each individual patient. Monthly oﬃce visits for up-dosing will be necessary until the desired SLIT maintenance dose is reached.

How long will the entire process take?

The ﬁrst-day procedure will take about 2-3 hours. If everything goes as per schedule, you will be at the desired SLIT maintenance dose (2+ mg food protein) in 5-6 months.

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Young boy smiling while doing the Oral Food Challenge

Man smiling after completing the Oral Food Challenge

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How often will the dose be increased?

Every 7 days at home, Once a month in the office.

How often will the dose be increased?

Every 7 days at home, Once a month in the office.

What time of day should home doses be given?

The dose can be given anytime up to the early evening and should be given about 24 hours apart. Avoid giving after 7 pm. The dose will need to be kept under the tongue for 2 minutes hold and then swallowed. No eating or drinking for 10 minutes afterward is preferred.

How long should my child stay awake after the evening dose?

Children should be observed for at least one hour after the dose is given. They should not be allowed to sleep during this time. Please avoid giving the dose after 7 pm.

How do we dose at home on the day of the monthly oﬃce appointment?

Please DO NOT give any dose at home on the day of the oﬃce appointment.

What if we are ﬂying when the dose is due?

Do not administer the dose less than one hour before boarding and do not administer the dose while ﬂying. A letter explaining the procedure and need for food SLIT solutions for the Transportation Safety Authority is available upon request. If not sure, skip the dose on the day of travel.

Frequently Asked Questions

If there is a reaction at home, what should I do?

Treat the reaction the same way you would any food reaction; the most common reaction is a mild itchy mouth or tongue, which is usually self-limiting and goes away without any treatment in a few minutes. Take an antihistamine if there is mild rash/hives. Use Epi-pen or Auvi Q if there are any symptoms of anaphylaxis. If the allergic reaction progresses, call 911 after the appropriate immediate intervention. Call our emergency phone after you have given appropriate initial treatment. We will give instructions on future dosing.

At what point can we start food OIT?

Most patients on food SLIT will be ready for OIT in 6 months. If needed, the food OIT can be started earlier, if we stop the SLIT sooner. The food SLIT and food OIT of the same food are not necessary at the same time. The food SLIT and food OIT for diﬀerent foods can be continued simultaneously. We will provide detailed information when you need it.

Does the food solution need refrigeration?

Yes. It is better to be refrigerated. Avoid putting it in the freezer. It is stable at room temperature for 24-48 hours if left out of the refrigerator for any reason.

What if we cannot come for an appointment due to travel or for any other reason?

Please stay on the same bottles and the current dose until you are seen in the oﬃce. Please let us know at least two weeks before you travel and we will provide speciﬁc guidance.

What if my child is sick and can’t take the doses on schedule?

If it is missed for 3 days, pick up on the standard dosing schedule. If it is missed between 4-7 days, please lower the dose to half for one day and resume the full dose the next day. If more than 7 days are missed, please call the oﬃce before giving the next dose.

What is the schedule once the maintenance dose is reached?

When the desired food SLIT maintenance dose has been reached, you will continue that dose daily. Many patients at that stage transition to food OIT. Those who choose not to start food OIT will continue food SLIT maintenance daily and will come every 2 months for the ﬁrst dose of new bottles in the oﬃce. Lab tests for food-speciﬁc IgE levels will be done regularly while on maintenance dosing.

Does my child need to avoid exercise during the food SLIT?

No. Exercise restrictions are not needed for food SLIT. There is no rest period required.

Can we do food challenges or other forms of immunotherapy or biologics during food SLIT?

1. Yes. You can schedule oral food challenges for other foods during food SLIT. Please do not give food SLIT dose on the morning of the scheduled oral food challenge.

2. Other forms of immunotherapy can be continued during food SLIT (for example - OIT for other foods, OIT maintenance for other foods, SCIT or SLIT for environmental allergens.

3. Biologics can be continued during the food SLIT as scheduled

If my child is allergic to multiple foods, can you do SLIT for more than one food simultaneously?

Yes. Each food SLIT protocol is food speciﬁc. More than one food SLIT can be started and administered for food allergy symptoms simultaneously. Ask us for more speciﬁc information for treating multiple food allergies.

What if my child does not get immunizations or is behind on scheduled immunizations, can he/she start the food SLIT program?

No. Your child must be up-to-date on all scheduled immunizations before starting any of the food SLIT or OIT programs.

Who can perform Sublingual Immunotherapy?

SLIT, or Sublingual Immunotherapy, must be administered by an experienced food allergy expert team, like NYFA. Dr. Atul Shah and his team at NY Food Allergy & Wellness have 3 offices. Locations on Long Island: Centereach and Shirley. Manhattan: 110 E 60th Street. Please visit https://www.center4asthmaallergy.com/ for locations on long island. And visit https://www.nyfoodallergy.com/ for our Manhattan location.

Where can I learn more about Sublingual Immunotherapy?

You can learn more about the Sublingual Immunotherapy, as well as all of the food allergy treatment options by watching success stories on our YouTube channels. NY Food Allergy & Wellness and Center4Asthma&Allergy.