Sublingual Immunotherapy: A Guideline-based Quiz

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Question 1.

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The correct answer is A. Odactra

Odactra was FDA approved in March 2017 for the treatment of dust mite allergy.¹ Oralair was approved by the FDA in 2014² for the treatment of allergy to five types of grass pollens common in the US. Grastek was FDA-approved in February 2015³ for the treatment of allergy to Timothy grass pollen. Ragwitek was FDA-approved in February 2015⁴ for the treatment of allergy to ragweed pollen.⁵

Question 2.

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The correct answer is B. False 

Starting ages for SLIT vary by product: 5 years for Grastek,³ 18 years for Ragwitek,⁴ 10 years for Oralair,² and 18 years for Odactra.¹ However, the upper age limit for all SLIT immunotherapies is 65 years, which reflects the ages of participants in the clinical trials reviewed during FDA approval. 

Question 3.

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The correct answer is D. Hives  

Local adverse reactions to SLIT include dysgeusia (altered taste perception), oral pruritus, swelling of the lips, mucosal edema, ear pruritus, swollen tongue, glossodynia (or “burning mouth syndrome,” referring to a burning or stinging sensation in the mouth), mouth ulceration, tongue ulceration, throat irritation, pharyngeal edema, nausea, upper and lower abdominal pain, vomiting, and diarrhea.  Hives is considered a systemic reaction. 

Question 4.

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The correct answer is B. False 

According to guidelines from the American Academy of Allergy, Asthma and Immunology (AAAAI),⁶ dosing equivalence between SLIT tablets and aqueous extracts of the same allergen cannot be assumed. No studies have directly compared the same allergen given in tablet or aqueous form. For this reason, the comparative efficacies and similar safety profiles are unknown. Furthermore, no SLIT aqueous preparations have been FDA approved.

Question 5.

One of your patients, a 22-year-old college student who is being treated with Grastek for Timothy grass pollen allergy, went on spring break and forgot to take his medication with him. He took his last dose 9 days ago.

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The correct answer is C. Decrease the SLIT dose  

According to guidelines from the AAAAI,⁶ a patient’s SLIT dose should be decreased if they miss more than 7 days of treatment, because of the risk of increased systemic or local reactions upon re-starting at the same dose. This recommendation is based on clinical trials that allowed treatment interruptions for up to 7 days. However, there is scant evidence to guide re-starting therapy after treatment interruption, and no controlled trials have looked at the safety of doing so.

References:

1. USFDA. Odactra. Accessed April 13, 2018 at: https://www.fda.gov/biologicsbloodvaccines/allergenics/ucm544326.htm 

2. USFDA. Oralair. Accessed April 13, 2018 at: https://www.fda.gov/BiologicsBloodVaccines/Allergenics/ucm391287.htm

3. USFDA. Grastek. Accessed April 13, 2018 at: https://www.fda.gov/BiologicsBloodVaccines/Allergenics/ucm393162.htm

4. USFDA. Ragwitek. Accessed April 13, 2018 at: https://www.fda.gov/BiologicsBloodVaccines/Allergenics/ucm393572.htm

5. AAAAI Allergy & Asthma Medication Guide. Accessed April 13, 2018 at: http://www.aaaai.org/conditions-and-treatments/drug-guide/sublingual-immunotherapy-slit-tablet

6. Greenhawt M, Oppenheimer J, Nelson M, et al. Sublingual immunotherapy: A focused allergen immunotherapy practice parameter update. Ann Allergy Asthma Immunol. 2017;118:276-282.e2.