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Usefulness Of Slit In Different Types Of Patients And/Or Circumstances

SLIT is useful for the management of allergic conditions in special populations, where treatment with injections could be riskier or more difficult to administer.38 Beyond the situation where the patient cannot cope with the idea of needles (“needle-phobia”) these situations include:

A) THE VERY YOUNG PATIENT

Present guidelines advise not to administer injection immunotherapy to children younger than 5 years of age. The reasons are related not only on the obvious difficulties to administer shots to young children, but also to the fact that if a severe reaction were to develop in a young child, it would be of more difficult management and potentially worse outcome.40  There is also a “perception” that the young child does not develop serious allergy problems. This is actually a misconception as it is common to find young children with nasal congestion significant enough to produce restless sleep which contributes to chronic tiredness. This in turn can contribute to behavioral problems and decreased school performance. It is also common to find young children with chronic cough, severe enough to interfere with the quality of the patient’s life. Chronic/recurrent cough could be a pre-asthma condition or already a mild form of asthma. Often times these children are treated with nebulizers with bronchodilators (Albuterol or Xopenex) and/or inhaled corticosteroids (Pulmicort® -budesonide-), not realizing that a positive response to these medications establishes the diagnosis of an inflamed lower airway which is a landmark component of the asthmatic condition. Asthma is defined as a reversible obstruction of the lower airways that is favored by the widespread inflammation that allergies and other environmental toxicants elicit in these patients.24

Even without cough it is important to know that a child that is diagnosed with nasal allergies has a 19% chance of becoming asthmatic some years after diagnosis of the allergic condition. While this fact was already recognized and published in the late 1960’s 41 it has been again clearly established in more recent times.42,43,44  While it is clear that the administration of injections to children can be problematic, the situation can be easily and safely managed by the administration of sublingual immunotherapy. This is very important because immunotherapy is the only treatment capable of preventing the progression from allergies to asthma.41,43,45 In other words: many European authors think that once a child is diagnosed with nasal allergies this child should be treated with immunotherapy as there is a very significant risk (1 in 5) that this child will end being asthmatic. Obviously these authors recommend SLIT as the first line of therapy, and given my experience managing allergic conditions I strongly adhere to that opinion: a child, when diagnosed with allergies should be treated with immunotherapy, in an ideal world, through the sublingual route (SLIT) as it is much safer than the injectable one.

b) THE ASTHMATIC PATIENT

Asthma implies an inflammatory condition of the lower airways. In normal circumstances the air that is breathed-in (inspired), goes through a series of progressively smaller tubes (bronchi, smaller bronchi and bronchioles) that eventually are so small that they are the size of small blood vessels (capillaries). These two types of tubules, the breathing ones (bronchioles) and the blood ones (capillaries) are one next to the other, and are so thin that the gases can diffuse (pass) from one to the other, so that the oxygen goes from the bronchioles to the blood and the waste gases in the opposite direction. (In other words, the inspired air will go from the atmosphere through the nose, into the trachea, into the lungs, (into the bronchi, then smaller and smaller bronchi until reaching the bronchioles) and then ultimately into the blood). This is called respiration, and obviously implies that the breathing tubes are open so that the gases freely move through them. In the asthmatic patient, because of the inflammation, and constriction of the bronchiole-muscles (muscle spasm, that narrows tube lumen) the air cannot easily get out from the narrowed smaller tubules (bronchioles) making it difficult for the patient to breathe.

The air-way narrowing and inflammation are responsible for the asthma symptoms: difficulty breathing that can be mild with a sensation of tight chest or severe enough to render the patient in real respiratory distress; and other symptoms like wheezing (a whistling noise that occurs when the air is pushed through narrowed tubules) and cough due to irritation of the linings (mucosa) of the lung structures. For more on asthma symptoms click here.

C) THE VERY OLD PATIENT

There are obvious difficulties for the senior patient to come to and from the doctor’s office. Many times the senior patient needs to rely on a friend or family member with an otherwise busy schedule for the transportation. The resulting situation is that often times the senior patient is deprived of a treatment that otherwise could be very useful.

There is a common misconception that the elderly patient does not have nasal allergies or that the elderly patient does not suffer significantly. Actually the opposite is true: elderly patients (often with decreased vision and decreased physical capabilities) commonly live in an environment with increased concentration of dust-mites and other allergenic particles. Often times the senior patient develops a chronic nasal congestion, chronic cough or recurrent headaches that significantly interfere with the quality of life. It is not unusual that these patients will end taking a several medications to treat (often with poor result) these symptoms that on the other hand usually respond very well to immunotherapy. Having the option of home-based immunotherapy is very important, and SLIT is the ideal home based immunotherapy.

D) THE PATIENT WITH A BUSY SCHEDULE OR LIVES FAR AWAY FROM THE OFFICE

A home-based immunotherapy treatment is easier to comply with than a treatment with injections that involve going weekly to the office (and waiting 30 minutes at the office after each shot). For the patient that lives far from the office, or the patient that has busy schedules, SLIT offers an excellent option to receive immunotherapy leading to symptom improvement and many times resolution of the underlying inflammatory condition that produced the symptoms. SLIT bottles can be mailed to patient’s home therefore there is not even the need to lose time in picking up the vaccine.

E) THE PATIENT THAT TAKES MEDICATIONS KNOWN AS BETA-BLOCKERS

If there was to be a reaction to an allergy shot, the treatment of choice would be Adrenaline. Adrenaline function could theoretically be blocked by the medications known as beta-blockers (BB), frequently used (amongst other indications) for the treatment of hypertension, heart conditions, migraines and glaucoma. As we said several times, even though the risk of a severe reaction to the administration of allergy shots is extremely low, treatment with SLIT is safer.

While we have treated patients on BB with allergy shots (our office was part of a national survey-study to find out if there was a real risk-increase in patients on beta blockers) we prefer to treat these patients with SLIT. While there is no published information on the role of SLIT in the management of allergic patients on beta blockers we found, over the years, no problems whatsoever with this particular group of allergic patients.

F) THE PREGNANT PATIENT

This type of patient also represents a challenging situation. Many allergy practitioners do not treat pregnant patients. There is the fear of what could happen to the fetus if a reaction were to occur and Adrenaline needed to be given. The guidelines for injectable immunotherapy establish that when the patient finds out she is pregnant, the injectable dose will not be increased until after delivery. Because there are no severe reactions to SLIT, sublingual drops appear to be the ideal management for the pregnant patient on immunotherapy.

Caution to pregnant patients:

Over the years we found that when patients on immunotherapy become pregnant their doctors advise them to stop immunotherapy. The patients and their doctors need to understand that allergy vaccines DO NOT contain any living organism. Besides, allergy vaccines being all natural can be properly processed and disposed by the body without eliciting any adverse events (which is not true when medications are used, as medications are foreign-to-the-body substances). When pregnant women interrupt immunotherapy they often return to the office during late pregnancy with severe nasal obstruction or other allergy symptoms that prevents them from attaining a good night’s sleep. At this time these patients are often treated with medications. Re-starting immunotherapy after discontinuing it is a much more dangerous situation than continuing with immunotherapy. That is why the appropriate management of the pregnant patient on immunotherapy is to not interrupt the treatment when patient becomes aware she is pregnant. If there are still concerns about safety, then SLIT should be considered.

Bibliography

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