Sublingual Immunotherapy Brings Options for Patients and Unchartered Waters for Clinicians
Mention you have allergies and everyone imagines the common sneezing, stuffy nose and itchy eyes. Many people are blissfully unaware of the misery resulting from persistent, severe allergies that interfere with daily life and cause everything from fatigue to headaches. Then they’re advised to avoid the allergen, but think about the challenge of avoiding dust or the trauma of being isolated from the beloved family pet.
People suffering from allergic rhinitis are always on the lookout for treatment options. While some have symptoms so severe they consult an allergist, many frequent local pharmacies as they search for over-the-counter medications and wait for allergy season to subside. Now that the FDA has approved sublingual immunotherapy (SLIT) for several types of pollen—and SLIT for other allergens is on the horizon—compounding pharmacists have the opportunity to build their business by reaching out to physicians and counseling patients who can benefit from compounded sublingual immunotherapy.
Current Treatment Guidelines
The first clinical practice guidelines for allergic rhinitis were published in February 2015, so they include the new sublingual immunotherapies approved by the FDA in 2014.1
Just like subcutaneous immunotherapy, the first step is establishing the presence of allergen-specific immunoglobulin E. Before choosing a treatment, patients should be assessed for comorbidities to determine whether the treatment plan should include medications for atopic dermatitis and asthma.
- The new guidelines haven’t significantly changed baseline treatment. They recommend topical steroids and oral antihistamines for pharmacological symptom control. Intranasal steroids should be considered for patients with severe symptoms. The practice guidelines also strongly recommend using less-sedating, second-generation antihistamines.
- Sublingual immunotherapy can be used in place of subcutaneous immunotherapy. Ideal candidates include patients with severe allergies, those with a poor response to pharmacologic treatments, and the presence of comorbid conditions.
Current and Future Sublingual Immunotherapy
Sublingual immunotherapy is currently available for allergic rhinitis caused by grass and ragweed pollen. Effectiveness is the same in children and adults, but it varies depending on the targeted allergen. Studies reported a 23 percent improvement in symptoms when sublingual immunotherapy was used for grass pollen.2 Clinical trials for ragweed pollen found that symptoms improved by 27 percent to 43 percent.3
Current sublingual treatments target one type of allergy, so future research will focus on SLIT for multiple allergens. Research is currently being conducted for dust mites and various food allergies, but the most exciting studies are focused on using SLIT to treat peanut allergies. Finding successful options is important because peanut allergies are among the most common and severe food allergies, and peanuts being the leading cause of fatal food reactions. So far the results of studies are promising. Using low allergen doses, SLIT has been safe and resulted in moderate desensitization.4
Caught at the Intersection of SLIT and SCIT
Sublingual immunotherapy has been called a game changer, but primary care providers and allergists are waiting to see if all the changes are positive. While SLIT may attract new patients who used to rely on OTC products, physicians anticipate a financial downside. SLIT might reduce the number of patients who choose subcutaneous immunotherapy (SCIT). This shift in treatment could impact the bottom line since SLIT costs less than SCIT.
Compounding pharmacists have to be aware of getting caught in the middle. The potential loss of OTC customers is an unknown variable, but you can optimize the likelihood of keeping SLIT business if you take steps to remain in the loop.
- Some physicians may want to offset the loss of SCIT income by operating in-house compounding services. You can turn the tide by proactively reaching out to form partnerships and by talking to physicians about the benefits of using an established compounding pharmacy.
- Compounding pharmacists are perfectly positioned to help physicians figure out cost and insurance issues. Since SLIT is currently used off-label, insurance may not pay. Some experts worry about insurance companies insisting that patients try SLIT before SCIT—a Catch-22 if they don’t cover SLIT. Until policies catch up with new treatments, pharmacists will benefit from working closely with physicians.
Facilitating Patient Outcomes
Since sublingual immunotherapy is taken by the patient at home, its effectiveness depends on adherence to the prescribed regimen. Prescribing physicians cover the bases, but compounding pharmacists can also influence patient safety and adherence. When you counsel patients, be sure to cover these key points to promote compliance:
- Patients need to understand that symptom control may be delayed so they don’t stop treatment thinking it doesn’t work. Be sure to emphasize the importance of taking every dose as scheduled.
- Make sure patients know how to take sublingual immunotherapy for maximum absorption.
- Work with the patient to ensure a constant supply of medication if they plan to travel.
- Remind patients about systemic side effects and make sure they’re prepared to use injectable adrenaline.
- Talk to patients buying OTC allergy products about sublingual immunotherapy.
- Put up eye-catching posters five months ahead of allergy season to get patients thinking about treatment because sublingual immunotherapy must begin three to four months before allergy season starts.
Take the Lead to Promote Healthy Choices
As more patients begin using sublingual immunotherapy for allergic rhinitis, and as more SLIT treatments are approved, pharmacists can simply wait and see how it changes the market or they can get ahead of the game, leading the way and becoming expert resources. Your active role promotes the health and well-being of patients while giving physicians the benefit of quality products and the information they need to help patients make informed decisions.
Pharmaceutica North America provides a variety of high-quality bulk APIs and premixed compounding kits that support your pharmacy. Please contact us today and talk to our experts so that we can help you become the leader in your field.
- “Clinical Practice Guideline: Allergic Rhinitis Executive Summary,” February 2015, http://oto.sagepub.com/content/152/2/197.full ↩
- “Efficacy and Safety of Grass Sublingual Immunotherapy Tablet, MK-7243: A Large Randomized Controlled Trial, December 2013, http://www.annallergy.org/article/S1081-1206%2813%2900903-4/abstract ↩
- “Randomized, Double-Blind, Placebo-Controlled Trial of Standardized Ragweed Sublingual-Liquid Immunotherapy for Allergic Rhinoconjunctivitis,” December 2013, http://www.jacionline.org/article/S0091-6749%2813%2901702-8/abstract ↩
- “Recent Advances in Immunotherapy and Vaccine Development for Peanut Allergy,” May 2015, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530404/ ↩