Looking forward to improving and lessening the allergic response

Image Credit: AdobeStock/Drazen

Looking forward implies the anticipation of something favorable. Do allergy sufferers look forward to a new season? What could they do now before the upcoming allergy season to reduce their symptoms?

As eye care professionals, we encounter patients with recurrent symptoms suffering from not only ocular allergies but also skin issues that significantly impact their quality of life. In addition to their ocular symptoms of itching, redness, and tearing that you discuss during an eye exam, ask about other allergy symptoms such as scratchy throat, postnasal drip, and skin rashes or breakouts.

At what point do you refer or suggest an allergist?

Some patients say these problems are only for 2 to 3 weeks during the high point of a pollen allergy and their symptoms are controlled by over-the-counter antihistamines and ocular therapies that you recommend or prescribe. For patients with more extensive, year-round allergies that are not well controlled, or if their allergy medications interact with their other prescriptions, consider sending them to an allergist/immunologist.

Allergy testing plays a crucial role in identifying specific allergens that trigger undesirable reactions. Allergists can perform skin tests and/or blood tests–specifically, immunoglobulin E (IgE) testing–to determine the allergens causing a patient’s symptoms. Allergies can be caused by various factors, including pollen, dust mites, mold, insects and/or pet dander. These tests help create a personalized treatment plan and guide patients toward the most appropriate intervention.

Potential allergy treatments

First, let’s discuss allergy shots, also known as allergen immunotherapy (AIT). Allergy shots work best for those sensitive to insect venom and/or inhaled allergens and patients who are older than 5 years, not pregnant, and without severe asthma or a cardiac condition. The allergy shots are also not indicated for food or latex allergies. Allergy shots are established as a successful treatment option and involve the administration of gradually increasing doses of allergens over time to desensitize the patient’s immune system. After an initial allergy testing to pinpoint which allergens to target, the extracts of those allergens are prepared. Initially, the shots are given once or twice a week, starting at a very low dose with gradually increasing amounts of allergens at the allergist’s office. Usually, the patient has to stay 30 minutes after each injection to be monitored for any immediate adverse reactions. This is called the buildup phase and may take 3 to 6 months. The allergist will determine the optimal dosage and frequency for the patient. Gradually exposing the immune system helps the patient build up a tolerance to the allergens as the body recognizes them as harmless substances, ultimately reducing or eliminating allergic reactions. This process stimulates the production of the antibody immunoglobin G to counteract or suppress the IgE response of histamine release when exposed to the allergen.¹

After the buildup phase and the effective dose has been reached, the patient will start their maintenance dose. Shots are now given less frequently, usually every few weeks or monthly. The patient will continue receiving the shots for a period ranging from several months to 5 years, as determined by the allergist. Once the treatment is completed, some patients may experience long-term relief from their allergies, but others may require periodic maintenance shots to sustain the benefits, which include reduced medication dependence.

Customized treatments, which are the hallmark of allergy shots, are tailored to each patient based on their specific allergens, ensuring an optical outcome. And although upfront costs may be higher, the long-term benefits and reduced medication and office visits for emergent issues make allergy shots a cost-effective option.

Allergic conjunctivitis is one of the most prevalent features of allergies and is probably the reason for many emergent visits to your office. Allergy shots, even during the buildup phase of AIT, have been shown to improve ocular allergy symptoms.² Allergy shots can also prevent the development of new allergies and decrease the risk of developing new onset asthma.³

Sublingual immunotherapy (SLIT) is an emerging alternative to traditional allergy shots. It involves administering allergen extracts under the tongue, gradually desensitizing patients to specific allergens. SLIT offers several advantages, including convenience, safety, and the potential for self-administration. It is FDA approved for the treatment of allergic rhinoconjunctivitis but not specifically for ocular allergies. Tablets, which are available in the US for timothy grass, five grass, ragweed, house dust mites, and trees, have been shown to have beneficial effects for perennial allergic rhinoconjunctivitis.⁴ However, SLIT did not prevent new allergic responses or asthma in the case of house dust mites.⁵ 

What about online options? There are at-home allergen tests, DNA tests, and food sensitivity tests. There are online eye exams, for goodness’ sake! What about a tailored therapy without having to go to an allergist’s office? Well, it is important to note that allergy shots or AIT should always be administered under the supervision of a qualified allergist. However, there are now allergy drops available online through multiple companies that start with an at-home IgE blood test that the patient collects and mails. No doctor’s office visit is required. However, for patients younger than 18 years, this is not an option. Also excluded are people who are pregnant, have lung or heart disease or uncontrolled hypertension, or are on a beta blocker. Patients who are taking oral steroids or are on chemotherapy do not qualify for online SLIT. Patient options may also be limited by the state where they live or the type of insurance they have (Medicare/Medicaid/Tricare). For example, the drop version is not FDA approved.

As eye care providers, patient education is an integral part of our exams. We can guide patients by suggesting other testing and explaining the expectations of AIT or SLIT.

This opens the door for co-management and collaborative relationships with local allergists. We do referrals with the proper history and diagnosis to aid effective treatment planning. We can also offer to see patients for follow-up visits to assess their ocular complaints (or lack thereof) and relay those findings.

Allergy testing, allergy shots, and SLIT are valuable tools in the management of allergies. We can play a crucial role in identifying patients who may benefit from these interventions, collaborating with allergists, and ensuring comprehensive care for our patients. By staying informed about the latest advancements in treatments, we can help our patients find lasting relief and improve their quality of life and allow them to look forward to enjoying the seasons.

References

1. Aalberse R. The role of IgG antibodies in allergy and immunotherapy. Allergy. 2011 Jul;66 Suppl 95:28-30. doi:10.1111/j.1398-9995.2011.02628.x

2. Bielory L, Mongia A. Current opinion of immunotherapy for ocular allergy. Curr Opin Allergy Clin Immunol. 2002 Oct;2(5):447-52. doi: 10.1097/00130832-200210000-00013

3. Lei DK, Saltoun C. Allergen immunotherapy: definition, indications, and reactions. Allergy Asthma Proc. 2019 Nov 1;40(6):369-371. doi:10.2500/aap.2019.40.4249

4. DuBuske L. Efficacy and safety of sublingual allergen immunotherapy. Allergy Asthma Proc. 2022 Jul 1;43(4):272-280. doi:10.2500/aap.2022.43.220036

5. Lim JH, Kim JY, Han DH, et al. Sublingual immunotherapy (SLIT) for house dust mites does not prevent new allergen sensitization and bronchial hyper-responsiveness in allergic rhinitis children. PLoS One. 2017 Aug 14;12(8):e0182295. doi:10.1371/journal.pone.0182295