Allergy Shots & Tablets (Immunotherapy)

Q. My new Allergist retested me for allergies for mold and trees. I tested positive for 28. I have been taking allergy shots for 43 years monthly. Yes, 43 years. I am 56 years old. My new doctor suggested that I stop taking allergy shots because she said they are no longer benefiting me. I am so confused. I have not had a cold and allergy problems for the past 20 years. I am so afraid that if I stop taking the shots, I will get sick again. I am so lucky to be very healthy and I attribute that to my allergy shots. What do you think? I just spent 1 hour on the web reading aaai and acaai and can't find a page where this addressed. The only I found was that I may feel good for 3 yrs. Isn't my body relying on these shots after 43 years. Please respond as soon as possible. My doctor wants me to make up my mind. She will keep me as a patient and continue to give me my regular shots for only 1 more year.

A. The most prudent path is to stop the shots for a while and see how the patient does. The three year concept comes from a study that only lasted 3 years and so the study didn't answer what truly happens- and that is some people are "cured forever", in others symptoms come back. My own policy is to recommend after 5 years that patients quit and see how they do. Many patients over the years stay well, others need to resume allergy shots. In that case after another 5 years they don't want to quit again and I understand that. I think the allergist's recommendation is sound since skin tests can be positive and patients are not symptomatic from the allergies. I hope this discussion is helpful.

Q. I forgot my allergy serum/extract at home and I need it for the summer (being spent away from home). My brother now has it and can get it to me in a few ways:

A. The best method is to carry it by hand in a small cooler with some ice. However, we do ship extracts by mail without ice. If you put it in checked luggage it will freeze and will be ruined. The amounts are small enough for it to pass through airport security.

Q. Does taking an antihistamine before getting allergy shots impact the effectiveness of the immunotherapy? I have seen occasional recommendations to take one in order to avoid a bad reaction, but I have not been able to find an answer to this concern. In addition, is it a problem if a patient has been doing this consistently, and then stops taking the antihistamine? Would it increase the chance of a negative reaction?

A. Data from immunotherapy for venoms suggests that antihistamine pre-treatment during the rapid build-up phase of immunotherapy reduces local adverse symptoms related to venom injections such as redness, swelling, and itching.  A 2001 study looked at the question of whether antihistamine therapy influenced the effectiveness of honeybee immunotherapy. Results of the 2001 study, conducted after patients were on venom immunotherapy for an average of 3 years, suggested that pre-treatment with antihistamines during the initial phase of immunotherapy improved the effectiveness of the immunotherapy.

Some allergists recommend pre-treatment with oral antihistamines with the goal of prevention of local adverse symptom at the site of allergen immunotherapy injections.  If a patient had been consistently taking antihistamines prior to immunotherapy, and stopped taking the antihistamines prior to immunotherapy, it is possible that they might have increased local irritation related to immunotherapy injections.  However, it is also possible that the patient might not experience increased local irritation related to immunotherapy injections.

I recommend that you discuss your specific history and your concerns with your allergist, in order to develop a plan that is personalized for you.

Q. My 15-year-old son has peanut allergy. Is SLIT available at this time as a treatment for this?

A. Unfortunately, there is no definitive treatment for peanut allergy at this time. Researchers continue to study desensitization methods to include oral dosing and epicutaneous (delivered to the skin through a patch) delivery.

The National Institutes of Health (NIH) did sponsor a study on sublingual immunotherapy (SLIT) for peanut allergy, which was published in 2013. This study did show promise, and many patients were able to consume more peanut powder at the end of the study than at the beginning of the study. 

Although these results were very encouraging, none of the patients who were treated with SLIT for 44 weeks were able to undergo a desensitization challenge without symptoms.

Your son’s allergist can help keep you updated on emerging research and methods, and help your family consider further strategies that may be helpful for your son’s care.

Q. Can long term allergy treatments provoke the body to become allergic to other things? My husband is following a 3 year anti-allergy program and he seems to have worse symptoms than before. In other words, he is now allergic to things he cannot identify.

A. Allergic sensitization generally increases over time, from childhood to adulthood.

Allergen immunotherapy (also called “allergy shots” or “AIT”) involves the administration of gradually increasing quantities of specific allergens until a dose is reached that is effective in reducing symptom severity from natural exposure (similar to a vaccine). The major objectives of allergen immunotherapy are to reduce responses to allergic triggers that precipitate symptoms in the short term and to decrease inflammatory response and prevent development of persistent disease in the long term. Data on allergen immunotherapy in children are interesting, as immunotherapy may prevent development of new sensitizations in children.

It is certainly possible that your husband has developed new sensitizations over time. Alternatively, perhaps with treatment of symptoms triggered by allergens, symptoms related to non-allergic triggers such as respiratory irritants or infections may be relatively more prominent. Allergen immunotherapy is not thought to provoke new sensitizations.

Your husband should discuss his symptoms, and potential strategies for managing symptoms, with his allergist.

Q. How can I decrease the chance that I have a bad reaction to allergy shots?

A. There are many things that you can do to decrease and manage your risk of a bad reaction. First and foremost is to wait the recommended 30 minutes in your allergist's waiting room. Studies have found this is the time period when most bad reactions occur, and it is important that your doctor be able to treat you quickly if you do start to have a reaction. If you leave before the recommended wait time and have a reaction outside of the allergist's office, the delay in treatment can result in a more life-threatening outcome.

Second, you should always let the nurse/doctor know immediately if you are experiencing any symptoms of a reaction, or notify your doctor if you ever experience these symptoms later in the day after your shot. Symptoms of a reaction can include itching, runny nose, itchy watery eyes, coughing, shortness of breath, hives, swelling, or just feeling like something is different from when you came in.

Other things that can decrease your chance of having a bad reaction is to not come in for your shots if you are having severe allergy symptoms, symptoms of asthma such as wheezing or shortness of breath or use of albuterol, or an upper respiratory infection.

You should also let your doctor know if you begin taking any high blood pressure medications, particularly beta blockers, since these can make it harder for your doctor to treat you if you do have a reaction.

You may want to discuss with your allergist a prescription for injectable epinephrine that you can carry with you on the day of your shots.

Q. I have a lot of allergy problems and I'm tired of taking medicine that doesn't work very well. Several of my family members take allergy shots at home and tell me I should do them, too. I called my local allergist and asked if they did allergy shots at home. I was told that they did allergy shots for their patients, but the shots had to given in a doctor's office. I'm confused. I am interested in allergy shots if they help, but why do some people do them at home and others in a doctor's office?

A. First, we should address allergy shots (also known as subcutaneous immunotherapy) in general. For people who have allergic nasal symptoms, asthma or atopic dermatitis, and are able to receive allergy shots, those shots have been shown to be very effective. As a board-certified allergist, I believe the best physicians to prescribe allergy shots are those trained as allergists (certified by the American Board of Allergy/Immunology).

While allergy shots are relatively safe, there is a low but real risk of a systemic allergic reaction to the shot each time you receive one. This is the reason allergists have their patients receive shots in a doctor's office and then wait for thirty minutes afterwards – to decrease the risk that a serious life threatening reaction occurs back at home, when you're no longer in reach of immediate medical help. Allergic reactions, whether they are to allergy shots, medications or foods, can progress rapidly and should not be taken lightly.

Q. I have seen some information on the internet that suggests that allergy shots can be more effective if given directly into a lymph node. Is this correct? If so, is this something that is available now?

A. The idea of injecting immunologic material into a lymph node (called intralymphatic immunotherapy) isn't new — it has existed for a number of years, mainly in the setting of experimental anti-cancer therapy. Targeted cancer immunotherapy, placed directly into a lymph node, may more effectively target the source of problems at a lower dose than would otherwise be needed.

Since we are always looking for ways to improve treatment of allergies, allergists are studying this idea — along with many others — to determine its potential. An article published in 2008 by researchers in Switzerland indicates this new approach might work well in allergy treatment. In this study of 165 people, a series of 4 doses of grass immunotherapy were injected into an inguinal (groin) lymph node. The intralymphatic therapy was found to be as effective in this group as 3 years of traditional allergy immunotherapy (subcutaneous immunotherapy). Subsequently, the same researchers in Switzerland have also shown this treatment's effectiveness in treating allergies to cat dander and bee venom — but these later studies were done in mice, not humans.

Intralymphatic allergen immunotherapy treatment remains experimental at this time and is not available as a treatment in the United States.

See your allergist to discuss immunotherapy options that are right for you.