Old Allergists and New Treatments

By Dr. Paul Ehrlich

Several times a year I get asked by new patients/parents if I will provide treatments they have read about on the Internet, principally oral immunotherapy (OIT) for food allergies and sublingual immunotherapy (SLIT), for both food allergies and environmental allergies. Sometimes the treatments are much more exotic, such as parasites and other live organisms, for a range of allergic conditions. I am not against using alternative treatments. Witness the fact that I have sent a number of patients to Dr. Xiu-Min Li’s private clinic where she uses traditional Chinese medicine (TCM)—more about that later. But I’m also not content to have patients dictate treatment. Discuss? Of course. Demand? No.

First for the two forms of immunotherapy.

OIT is not approved for private practice. The raw material of treatment is, of course, available at any supermarket, so in theory and in fact, it can be offered by any allergist, or indeed any doctor willing to take the risks. I will not comment on the issue of FDA approval and whether the treatment is “ready for prime time.” It is not for me, however. Even if I overcame my reservations about the state of the research and bought into one of the protocols being used in private practice, I believe this will eventually involve a sub-specialty of allergy and immunology, as indeed, is the de facto case already. Deliberate daily exposure to a food allergen requires round-the-clock availability that I am not prepared to give. I am already essentially on call for all my patients, especially those with bad asthma, but because they are compliant using a familiar palette of treatments, the emergencies are few and far between. Would this be the case if I suddenly added OIT to my services? I would have to learn the protocols and be prepared to accept them as gospel. My practice colleagues would have to learn them, because no one can be on call all the time. This new treatment would come at the expense of what we already do and do well, and shortchange our patients.

SLIT is approved in a limited way, since, as Larry wrote a few months ago, several products for a few seasonal allergies have come on the market. I am aware that some private practices use it for other things, including food allergies. The therapeutic agents are available in the form of drops and maybe tablets manufactured by specialty suppliers. There’s nothing dangerous about them to the vast majority of the population. The research on SLIT for food allergies is quite advanced, although hardly conclusive. As I understand it, SLIT is slower at achieving desensitization than OIT and less reaction prone, but my reservations about using it for anything except environmental allergies are “OIT-lite.” That is, while food allergy SLIT may be less reactive and avoids the esophagus, I would still have to recast my practice to accommodate it.

Furthermore, even for environmental allergens there’s the matter of compliance. People find lots of reasons for not taking their medicines. Larry’s account of the Netherlands study, which showed that SLIT patients are even less likely to finish their therapy than those who get shots, is a case in point.

I know of one practice that has used SLIT for decades with a good deal of success (although there are problems). If you are going to use this kind of therapy, that’s the kind of practice you should go to, one where current practitioners are either pioneers or who have worked directly with the pioneers. Medical knowledge has what we might call, for want of a better term, a common core, but the kind of doctor you become also depends on the doctors who teach you.

Very occasionally I have agreed to work with patients who are determined to use treatments they have brought to me. They have researched these things very carefully and they satisfy me that there’s nothing inherently harmful about the therapy. They are, furthermore, so desperate for relief that I know they are going to use it anyway, so I agree to provide oversight.

To return to an alternative medicine that I am open to, there’s the brand of TCM practiced by Dr. Li. We share patients whose active diseases, including recalcitrant eczema and steroid-resistant asthma, are too stubborn for standard treatment. There is, moreover, a relentless research effort, which I am pleased to support. I don’t provide the treatment and it’s unlikely that I ever will except under her supervision. However, I am happy to provide the mainstream allergy support because I think that together we can make a difference in patients’ lives.