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    Current Standards of Care & Advances in Immunotherapy

A Roundtable Discussion:

The Current and Future Role of the Allergist in Immunotherapy

Listen to the Podcast

Panelists

Dr. Lanier:  We’ve talked about the science of sublingual immunotherapy and its effects on patients.  At some point we also have to talk about what the effects of sublingual immunotherapy will be on the allergists.  I think we stand at a precipice, much as dentists did back in the 1950s when people began to suggest that you could put fluoride in the water and prevent tooth decay.  It basically destroyed the dentists’ economic base of practice.  To their great credit they did not resist and went along with therapy for the good of the patients. Now we have a form of therapy that allergists in general find threatening because it does not require much expertise to administer, at least from what we’ve been told about its safety.  Some allergists are looking at this as a major threat.  In Europe, they basically had subcutaneous immunotherapy legislated out in a very short period of time; allergists really had no choice.  But in this country one wonders how we will mix sublingual and subcutaneous or indeed whether the practitioner will still exist after a certain point.

Dr. Cox:  I’ve been looking at the financial tracking data on the websites of some of the major extract manufacturers.  The increase in the subcutaneous market has been fairly consistent, between 8 to 12 percent during the past four or five years as SLIT was growing at the same time.  So SLIT doesn’t appear to be cannibalizing SCIT but rather is increasing the market by bringing attention to immunotherapy in general.

Dr. Bernstein:  I think general physicians realize that there is risk associated with this treatment and recognize that the allergist has a role in assuring its safety and that proper patient selection also is considered. 

Dr. Blaiss:  I think a big concern is that some non-allergists will simply do a serum specific IgE test to determine what a person is “allergic to” and then start him or her on sublingual immunotherapy.  That would be a great disservice for the patient.  I think the real issue is that it takes a clinician – the allergist – to do the history, physical exam and whatever in vivo or in vitro studies are done to diagnose the patient and correlate that with the patient’s history to determine what the proper treatment is and whether it should be subcutaneous or sublingual.  So this is not just giving an antihistamine for a patient who’s sneezing and has a runny nose.  It does take a specialist.

Dr. Wallace:  I would say to the general public and to primary care physicians that allergists are not “shot docs.”  Allergists are specialists in the field of allergy, asthma and all areas of allergic and immunological disease and we’re there to evaluate the entire patient, not just to deliver one particular type of treatment.  If immunotherapy happens to be indicated, then yes we are the specialists who administer that.  And while both skin test and specific IgE are risk factors, they do not make the diagnosis of allergy.  That comes with expertise and evaluation, taking the time to talk with the patient about the entire scope of disease and then correlating, as Dr. Blaiss said, the clinical findings, the physical exam and the in vitro or skin testing results.

Dr. Cox:  I think physicians who treat allergy should have expertise in the local and regional aerobiology.  This is not something that one learns in primary care training and it’s important when you’re evaluating a patient and planning to prescribe specific immunotherapy that you are very familiar with the regional aerobiology.

Dr. Bernstein:  The outcome that we see in our surveillance site – two years, no fatalities – may be a result of improved medical practices on the part of board-certified allergists.

Dr. Wallace:  We also teach the patient ways to avoid their allergens, ways to treat their disease and ways to understand and recognize if there’s and adverse event such as anaphylaxis.   Above all, we need to be able to treat anaphylaxis in the office setting and teach the patient to make us aware of delayed reactions if they occur.

Dr. Lanier:  It doesn’t always matter how good allergists are.  It’s what the perception is in the general community.  Studies we’ve done at the College show that primary care physicians don’t really necessarily feel like allergists have a special pool of knowledge.  And if you look at what we do and what we own – such as anaphylaxis, nobody else wants to fool with that; and drug sensitivity and immunotherapy, primarily because of its risk.  Now, the risk is being removed, which would play to a larger audience and in some respects even the diagnostics because with limited numbers of sublingual immunotherapy modalities; i.e., grass and ragweed for the most part (and grass doesn’t really apply to the Southern portion of the country) the blunderbuss effect occurs because people say it doesn’t matter what you’re allergic to, we’ve only got one or two things to treat you with anyway.  And even if you’re not grass-allergic you might get value from it.  So the question we’re going to get in the next couple years, at least from the family physicians and others, is why do we need you except for things we can’t manage ourselves like urticaria or extreme asthma?  Certainly not for allergy, which is generally covered as a portion of the curriculum for family physicians, interns and pediatricians.  They feel they do a good job in pharmaceutical management and therefore our role at some point is going to have to be redefined.

Dr. Cox:  I see the glass as half full; I know we’ll be around.  For many years, immunotherapy has been the Rodney Dangerfield of medicine; it’s got second-class citizen status.  As we get better immunotherapy products and more data come out on the preventative and cost-effectiveness aspects of immunotherapy, it will start taking its rightful place in the treatment of allergic disease.  We really need to start promoting it.

Dr. Finegold:  And one of the things that came out of the Parameters is the expansion into other diseases.  Now, atopic dermatitis used to be managed by the allergists and then we lost it to the people who put steroids on it all the time.  Perhaps now we’re going to regain it because there’s some skill in treating atopic dermatitis. It’s not the same as treating allergic rhinitis, but you do get good results with immunotherapy, both SCIT and SLIT. 

Dr. Bernstein:  I think we need more long-term cost outcome studies showing the value of this treatment over conventional pharmacotherapy.

Dr. Cox:  Yes, which I think we will see.  Because pharmacotherapy goes on and on and on, whereas you stop immunotherapy and that cost will go away and the clinical benefits may remain.

Dr. Wallace:  And certainly in the short term I think most primary care physicians would not be interested in doing cluster therapy, which we talked about as being a very, very good option for many of our patients at this time.

Dr. Finegold:  And Linda’s data from Florida on Medicaid patients29,30 shows that for allergic rhinitis, immunotherapy is very cost-effective. 

Dr. Cox:  Yes, we have something that’s been submitted as an abstract, so it’ll be out in March 2011.  We did a study of immunotherapy in patients with new onset allergic rhinitis in the adult Florida Medicaid population and compared them with five matched types of controls for age-of-onset and co-morbid conditions, and looked at 11 years of data.  We found significant reductions in median total health care costs beginning at three months and increasing over an 18-month period.  That included pharmacy and outpatient/inpatient costs.  It was a 50 percent reduction in total health care costs.  I think that’s huge.

Dr. Lanier:  For many years we’ve resisted thinking of oral immunotherapy of any kind and basically conveyed to our primary care physicians and people that refer to us that this is either placebo or worse, that it didn’t really have any value.  Now we’re going to have the odd circumstance of actually doing what we in many cases have condemned in the past – this is a generational phenomenon, I assume.  It’s a cultural experience that we’re all going to have to go through.

Dr. Blaiss: So we’ve had the first 100 years of immunotherapy and the real excitement now is the changes that we’ve talked about for the next 100 years that I think are going to be a great advantage for our patient population.

Dr. Lanier:  What we always have to remember with any form of therapy, is what’s going to benefit the patient long-term?  How are we going to do this better?  If it’s sublingual – or any form of immunotherapy – if it’s better, faster, cheaper or will benefit a greater number of people for a longer period of time, we’ll all join the chorus.

References

Other topics:

• Sublingual immunotherapy (SLIT)
• Subcutaneous immunotherapy (SCIT)
• Other immunotherapy delivery methods (intranasal, epicutaneous and intralymphatic)

Perspectives Article published in the November 2011 issue of Annals of Allergy, Asthma and Immunology.

 
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