Sublingual Immunotherapy for Food Allergies

Sublingual immunotherapy (SLIT) is a form of immunotherapy in which a liquid form of the allergenic food is placed under the tongue, held there for 1 minute, then swallowed. Food allergens come in contact with oral mucous membranes and are presented to T lymphocytes which slowly induce tolerance over time. The treatment requires four approximately 2-hour office visits for treatment dose increases, occurring every 1-2 weeks until the maximum dose is reached for maintenance. Home doses are given on a daily ongoing basis.

Goals of Immunotherapy

SLIT is intended to reduce the severity of allergic reactions, including anaphylaxis, that could occur from accidental exposure to the food allergen. The triggering food should continue to be avoided outside of scheduled dosing, and the final dose is intended to be continued indefinitely. This therapy gradually decreases the sensitivity to small amounts of the allergen that may be hidden in foods. SLIT is not a cure,nthough it may be disease-modifying. After each year of therapy, an oral challenge to small amounts of food are performed in the clinic to determine the safe level of exposure going forward.

Safety/Risks

SLIT has been used to treat food allergy for the last 20 years. Fatal reactions to SLIT have not been reported, and serious reactions are rare. The most common side effect is itching of the mouth, which occurs in most patients and gradually improves over time. Moderate side effects (eye itching, nausea/vomiting/diarrhea, hives, and wheezing) occur in about 1 in 12,000 doses. It is recommended to keep an epinephrine autoinjector (EpiPen/Auvi-Q/neffy) available at all times.

SLIT Vs. Oral Immunotherapy

Compared to oral immunotherapy (OIT), with SLIT there are fewer side effects and food aversions and less dose-related anxiety for patients. There are fewer office visits (4 compared to 12+ with OIT), but each visit will require 2-3 hours of time in the office while doses are given, with at least 1 hour of monitoring after the last dose is given. There are fewer activity restrictions after dosing, and there have been no reported cases of eosinophilic esophagitis. Because the dose being given with SLIT in much lower, it may take longer to see an ongoing effect, which may be measured by performing oral challenges each year. These differences are summarized in the following table

Practical Tips For SLIT

  • SLIT should be placed under the tongue, using a small syringe to draw up the dose

  • Do not swallow for at least one minute after use

  • Do not brush teeth or eat or drink for 5 minutes after use

  • Wait 15-30 minutes after SLIT dosing for any high-intensity exercise

  • One minor symptom (a few hives, itchy mouth, or runny nose) can be monitored or treated with antihistamine (Zyrtec/cetirizine, Claritin/loratadine, Benadryl/diphenhydramine)

  • Always have epinephrine (EpiPen, Auvi-Q, neffy) available and use for any episode of vomiting, facial swelling, or shortness of breath, and notify your doctor

  • SLIT extracts have glycerin/preservatives so they are fine for hours or days at room temperature, but most of the time SLIT bottles should be stored in the refrigerator

  • Contact the clinic if more than 5-7 doses are missed in a row

Interested in Sublingual Immunotherapy for Food Allergies?

Dr. Joshua Phillips currently offers sublingual immunotherapy to peanuts and other foods on a case-by- case basis. Call for an appointment to discuss the risks and benefits of this treatment.