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Allergy “Shots” Without the Sting

A pill under the tongue—does oral immunotherapy really work?

Young boy with his tongue out.
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Dear Doctor,

My son has terrible allergies, and we are considering allergy shots, but he really hates needles. I heard that there are special tablets he can put under his tongue instead. Is this true?

Sincerely,
"Mom of a Needle-phobe"

Dear Mom of a Needle-phobe:

It is true! Sublingual immunotherapy is very much real, and it's becoming increasingly accessible. In fact, the majority of U.S. allergists are now offering this option to patients, according to a recent study published in the Annals of Allergy, Asthma and Immunology.

But is it the right choice for your son?

Most allergy medications on the market are oral antihistamines—which work by stopping the production of a chemical that your body produces when it's confronted with an allergen—or nasal steroids, which tame inflammation. Immunotherapy, which includes both traditional (subcutaneous) allergy shots and oral immunotherapy tablets, works differently: It involves giving you very small amounts of the allergen that bothers you. The concept is that when you expose yourself to it over a period of time, you teach your immune system to tolerate it and stop treating it as a dangerous invader that must be attacked.

Allergy shots have been around for more than 100 years, and they're incredibly effective. Most people get them for three to five years (weekly, at least in the beginning), but the protection they offer usually lasts much longer. Oral immunotherapy is much newer—the first tablet was FDA-approved in 2014—so we don't know as much about how long the results will last. Instead of getting an injection that contains one or more allergens, you put a dissolvable tablet under your tongue. Each tablet contains tiny amounts of a single allergen; so far, this option is only available for allergies to ragweed, grass, dust mites, and cats. If you're allergic to all of these, you'll have to take four separate tablets. If you're allergic to other substances (mold, dogs, etc.), they won't help.

Traditional allergy shots, in contrast, help with a much wider range of allergens. Plus, allergists create a custom blend for each patient: That means you could start building immunity to any number of allergens with each injection. Shots also seem to be more effective than oral tablets, so they're likely a better pick if your symptoms are very severe. That said, they also carry a risk of allergic reaction, which is why you'll have to physically come into your doctor's office to get them and sit there for 30 minutes afterward to ensure you’re not having a negative response.

Oral allergy tablets are taken at home daily. Allergic reactions with oral immunotherapy are very rare, but they are possible, so if you use them, you'll need a prescription for an EpiPen as well.

Another factor to consider is cost. Depending on your insurance, you might have to shell out one co-pay every time you go for allergy shots. (Some insurers don't consider the injections an "office visit," so there's no fee at all.) Oral immunotherapy tablets should be covered by your insurance to a certain extent, but the amount of coverage can vary. Since you'll have to take the tablets every day year-round, it's smart to check with your insurance company first and figure out how the numbers would add up.

Most of my patients choose traditional allergy shots, but if you're averse to getting injections, too busy to come into the office once a week, and are only allergic to ragweed, grass, dust mites, or cats, then sublingual therapy might be a good option for you.

“The concept is that when you expose yourself to [an allergen] over a period of time, you teach your immune system to tolerate it and stop treating it as a dangerous invader that must be attacked.”
Dr. Punita Ponda, allergist

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Published August 6th, 2019
A young woman with dark curly hair is using mobile phone. Female is smiling while holding smart phone. She is lying on sofa at home.

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