Transcript 30 Years of SLIT:

Lessons Learned in 35 Years of
Experience
George F. Kroker MD FACAAI
On Experience…
 Experience: that most brutal of teachers.
But you learn, my God do you learn…
 C.S. Lewis
 Experience is the best teacher, but the tuition
is high…
 Old Norwegian Proverb
 Experience is simply the name we give our
mistakes…
 Oscar Wilde
Copyright 2015 Allergy Associates of La Crosse
David Morris M.D.
Copyright 2015 Allergy Associates of La Crosse
General Tips
Copyright 2015 Allergy Associates of La Crosse
“It’s not about the car, …it’s
about the driver”
 SLIT is one technique for treatment
 Use of SLIT does not compensate for a
lack of addressing the Total Allergy
Load in a patient
 Corollary: SLIT doesn’t make you a
good allergist, it allows you to be a
better allergist
Copyright 2015 Allergy Associates of La Crosse
The Clinical History
“The best diagnostic tool an allergist can wield is
not the skin test needle between his fingers, but
the grey matter between his ears…never forget
that the single best allergy test is a thorough
clinical history taken by an experienced
allergist…”
Copyright 2015 Allergy Associates of La Crosse
The Clinical History
 Take the history yourself, and learn to
ask questions other doctors don’t ask!
 Find out what the patient’s chief goal
is, not just their “chief complaint”
 Take the history before reviewing
outside lab data..be unbiased!
 Read “How Doctor’s Think” by Jerome
Groopman
Copyright 2015 Allergy Associates of La Crosse
The Clinical History--learn to
ask questions other doctors
don’t…one example
 Have you taken a trip and if so, noticed
a change in how you felt?
 Example:
the woman who traveled to
Thailand
 Example: the woman with rhinitis, s/p
colonoscopy
 Example: the man who went Elk Hunting
Copyright 2015 Allergy Associates of La Crosse
Approaching the established
patient who’s relapsed
 Review chart and find a spot where they
were doing well—review what they were
doing at that time
 Possible causes:
 Poor
compliance
 New/ Higher allergy load at work or home
 New medication reaction
 New medical condition
 More stress
Copyright 2015 Allergy Associates of La Crosse
“Stress” can profoundly affect
the allergic condition
 A stressful period in life may herald the
onset of allergic disease
 Example:
woman observing death of 2 sons
and then developing asthma
 Example: woman with urticaria developing
the day of a funeral, and continuing yrs after
 May be helpful for a patient to understand
“why their allergy started now”.
Copyright 2015 Allergy Associates of La Crosse
Stress & Response to SLIT
 “Psychological stress affects response to
sublingual immunotherapy in asthmatic
children allergic to dust mites”
 Ippoliti

F., et. Al. Pediatr Allergy Immmunol
Vol 17(5):337-45, 2006
Copyright 2015 Allergy Associates of La Crosse
Stress & Response to SLIT
 40 dust-mite sensitive asthmatics were
treated with SLIT
 Divided after 6 months into 2 groups (low
& high stress) based on results of stress
integrated measure (SIM)
 Asthmatic symptom score, PEF and ECP
showed greater improvement in nonstressed patients
Copyright 2015 Allergy Associates of La Crosse
Stress & Response to SLIT
 Authors conclusions:
 “Our
findings show that psychological stress
can affect response to SLIT Rx in allergic
subjects and are consistent with data recently
reported showing a correlation between stress
and poor response to antimicrobial vaccines.
Our data also suggest that stress evaluation
may become a useful prognostic factor in
immunotherapy.”
Copyright 2015 Allergy Associates of La Crosse
“Stress” can significantly affect
response to SLIT and relapse
risk going off SLIT
 Clinically, highly stressed patients may
take longer to respond to SLIT than the
typical patient
 Be cautious about discontinuing SLIT in a
highly stressed patient—even if they are
doing well. They are at an increased risk
of relapse going off of treatment
Copyright 2015 Allergy Associates of La Crosse
In the new patient who failed a
course of SCIT, consider the
following:
 Technical failure of treatment (i.e., all
antigens found, but not treated well, lack
of compliance, etc.) esp dust or mold
 Failure due to lack of addressing another
hidden allergen (i.e., all allergens not
found)
 Failure due to overwhelming allergic load
Copyright 2015 Allergy Associates of La Crosse
The patient unresponsive to
your SLIT treatment:
 Technical failure: “treating the right
allergens, but doses insufficient” or
compliance issue
 Diagnostic failure: other allergens
undiscovered and unaddressed
 Failure due to overwhelming allergic load
Copyright 2015 Allergy Associates of La Crosse
The “Total Allergy Load”
is your friend
Copyright 2015 Allergy Associates of La Crosse
Use metaphors to help patients
understand the role of SLIT and
The Total Allergy Load
 “Teeter-totter” metaphor
 “Physical Therapy” metaphor
 “Overloaded boat” metaphor
 The “child with the building blocks”
metaphor
Copyright 2015 Allergy Associates of La Crosse
Remember the Teeter-Totter
The Untreated Patient
Tolerance
SLIT
Copyright 2015 Allergy Associates of La Crosse
Allergic Load
Lower
Allergic Load
The “Physical Therapy”
Metaphor
 Having a musculoskeletal sprain is like
having a “sprained” immune system
 Treatment of the sprain and allergy is very
similar
 Rest
(“reduce allergy load”)
 Antiinflammatory meds in both cases
 Physical therapy (SLIT)
Copyright 2015 Allergy Associates of La Crosse
The “Overloaded Boat”
Metaphor
 “Throw cargo


Copyright 2015 Allergy Associates of La Crosse
overboard”
(allergens you can
do without)
“Get boat to dry
dock” (safe environ)
Fix the hole(s)
(SLIT)
The “Child with the Building
Blocks” Metaphor
For my “sometimes” patients
Allergic
Threshold
Copyright 2015 Allergy Associates of La Crosse
Prior sites of trauma can be “target
organs” for reactions:
SLIT can help
 Patient with herpes zoster & corn allergy
 Patient with ear trauma & wheat allergy
 The patient stung by a jellyfish who had
a drug reaction
 The former football player who had knee
pain in the fall allergy season
Copyright 2015 Allergy Associates of La Crosse
A new and strange symptom in an
established allergy patient is a
drug reaction until proven
otherwise
 Patients with a new symptom unlike their
“usual rxns” may be having a drug rxn
 Example:
pt with chlortrimeton-diarrhea
 Example: pt hosp with asthma, eosinophilia
 Example: pt with chronic cough from fosamax
 Corollary: Any pt can react to any
medicine at any time with any symptom
Copyright 2015 Allergy Associates of La Crosse
Inhalant Allergy
Tips
Copyright 2015 Allergy Associates of La Crosse
Skin test
 Remember the skin test is a “surrogate
marker” for reaction in other parts of
the body
 Some patients (allergic conjunctivitis)
may have minimal skin test reactivity
but still react in the eyes
Copyright 2015 Allergy Associates of La Crosse
Skin testing
 Remember skin test sites have a
“memory” (resident T memory cells)
 An allergenic exposure may trigger a
reaction at prior skin test sites
 Most often caused by molds
 Example: A boy who mows the lawn
Copyright 2015 Allergy Associates of La Crosse
Skin testing
 An unexpected increase in a skin test
reaction to a pollen is often because of a
coexisting cross-reactive food ingested
 Especially common with birch and
ragweed patients
 If patient had a recent skin test to a
pollen, ingestion of the fruit may cause
the skin to itch at the test site
Copyright 2015 Allergy Associates of La Crosse
Food Allergy
Tips
Copyright 2015 Allergy Associates of La Crosse
SLIT for inhalants helps cross
reacting food allergens
 Treating a tree allergic patient can help
them tolerate fruits causing OAS
 Usually requires pre-seasonal dosing
coupled with increasing threshold
dosing of offending pollen
Copyright 2015 Allergy Associates of La Crosse
A “fixed eruption site” triggered by
foods can be helped with SLIT
 Patients may have a unique site
sensitized by contact that is
subsequently triggered with foods and
sometimes inhalants
 Example:
pharmacist with PCN & corn
allergy
 Example: patient with cosmetic reaction &
milk allergy
Copyright 2015 Allergy Associates of La Crosse
A mold sensitive patient is also
allergic to food yeast and
Candida until proven otherwise
Airborne
molds
Food
Yeast
Copyright 2015 Allergy Associates of La Crosse
Candida
Albicans
Pearls for Candida Related
Illness
 Candida Related Illness=
high colonization + high sensitivity
 Best diagnostic test is observing skin test
for inappropriate immediate & late rxns
 Treatment should always include SLIT
 Antifungal medication “dependency” can
usually be helped with SLIT for Candida
Copyright 2015 Allergy Associates of La Crosse
Pearls for Candida Related
Illness
 Candida patient may have trouble tolerating



mold SLIT Rx until Candida reduced in body
Mold and Candida often give same
symptoms
Heavy mold exposure makes pt more
reactive to Candida
Heavy Candida exposure makes pt more
reactive to mold
Copyright 2015 Allergy Associates of La Crosse
Modify treatment with acute
viral gastroenteritis
 Patient at short-term risk of reacting
more to prior food allergens
 Advise temporarily resuming
hypoallergenic diet & reducing SLIT to
once daily
 Example:
patient with food poisoning
 Example: wheat allergic patient with GI flu
Copyright 2015 Allergy Associates of La Crosse
The inhalant allergy patient
with “GERD” has a food
sensitivity until proven
otherwise
 Food allergy may aggravate “GERD”
 Dairy and gluten most common culprits
 Often these patients have not
responded to traditional anti-GERD rx
Copyright 2015 Allergy Associates of La Crosse
The allergy patient with
“treatment resistant GERD”
may have eosinophilic
esophagitis
 Food allergy may aggravate both
“GERD” and eosinophilic esophagitis
 Remember that eosinophilic
esophagitis may be triggered by
inhalants—”seasonal esophagitis”
 Example:
Boy mowing lawn with GERD
 Example: Woman with acute attack in
summer
Copyright 2015 Allergy Associates of La Crosse
Treatment
Tips
Copyright 2015 Allergy Associates of La Crosse
Treatment Observations
 In the multi-sensitized patient with
active allergy symptoms and a high
Total Load, start with the optimized
threshold dose and consider a “minibuildup”:
1
pump /d x 1 week
 2 pumps/d x 1 week
 3 pumps/d thereafter
Copyright 2015 Allergy Associates of La Crosse
Treatment Observations (cont)
 The motto is “Go Slow” when you begin
SLIT Rx for molds in a patient with
mold overload in their home
 Higher incidence of side effects
 Pre-treatment with antifungal
medications in the above situation may
help patient better tolerate SLIT
Copyright 2015 Allergy Associates of La Crosse
Treatment Observations (cont)
 SLIT Rx may help a patient with a
physical urticaria to have improved
tolerance to cold, heat, or pressure
 Lowering the total allergy load has the
same positive effect
 Example:
“the baseball player”
 Example: “the wildlife and fishery worker”
Copyright 2015 Allergy Associates of La Crosse
Treatment Observations (cont)
 If a patient has side effects from
inhalant and food treatment bottles, and
the side effects are identical, they are
glycerin sensitive until proven otherwise
 Corollary: be careful about using
glycerin containing extracts in a patient
highly sensitive to multiple soaps,
shampoos, creams, etc.
Copyright 2015 Allergy Associates of La Crosse
Preseasonal Treatment
 Preseasonal treatment poses less risk
of side effects when used in a monorather than multi-sensitized patient
 Be careful with multi-sensitized
patients—consider #3 instead of #2 dil
 Example: Patients “primed” with
Alternaria may have trouble handling
preseasonal grass treatment
Copyright 2015 Allergy Associates of La Crosse
Tip #1: Restated
“The best diagnostic tool an allergist can wield is
not the skin test needle between his fingers, but
the grey matter between his ears…never forget
that the single best allergy test is a thorough
clinical history taken by an experienced
allergist…”
“The best therapeutic tool an allergist can wield
is LCM SLIT given in an appropriate protocol by
an experienced allergist”
Copyright 2015 Allergy Associates of La Crosse
Thank you
Next:
Wrap up
Q&A
Mary Morris MD and George Kroker MD
Copyright 2015 Allergy Associates of La Crosse