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From the Townsend Letter
April 2016

Allergy and Immunotherapy
by Diego Saporta, MD, FAAOA
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Low-Dose Allergen Immunotherapy (LDA)
This treatment modality, while being effective, does not conform to "usual" immunotherapy. With LDA, allergens are diluted to the order of 10−6 to 10−17. A major controversy about this treatment is a lack of understanding about its mechanisms. An attempt to get approved by the FDA failed.51 LDA efficacy information is mostly anecdotal. It uses proprietary information in its formulation, and there is only one source for the treatment sets.52 LDA reportedly uses all allergens present in the environment as well as foods. Immediately before administration these allergens are mixed with the enzyme beta-glucuronidase.

Knowledge of LDA stems mainly from observations of Dr. Leonard McEwen, a British allergist who realized that beta-glucuronidase had antiallergenic properties. The treatment was popularized in the US by Dr. Welman Shrader.51 The most remarkable fact about LDA is that it works. LDA is administered initially once every 2 months. It takes usually 12 to 18 months to attain a 2-month improvement, at which time the interval between administrations is increased. Eventually the patient can be managed with treatments once a year or longer.51

LDA advantages:
Administration is based on a clinical diagnosis of the allergic condition. An allergy test is not necessary because:
a.   All allergens are covered; therefore there is no need to diagnose which are the responsible allergens.
b.  The administered dose is so diluted that it will never give a reaction as can happen with SCIT; therefore the concept of "safe dose to start immunotherapy" does not apply.
The cost of this treatment decreases over time, since the number of administrations diminishes as the patient improves.
LDA administration treats hypersensitivity to not only inhalant allergens but also foods. The prevalence of food reactivities is on the rise worldwide. The patient with allergies commonly reacts to one or more foods. There are no FDA-approved therapies for food allergy.53 The standard of care consists of allergen avoidance and, if needed, prompt treatment of allergic reactions after accidental ingestion. Oral and sublingual food immunotherapy are being evaluated, and reports are optimistic.53,54 LDA offers another option for the management of food allergies and reactivities.
Anecdotal information suggests that LDA is effective.51 In a study comparing results of patients treated with LDA or with standard immunotherapy, no statistical differences between the groups were found, but the LDA group included patients who failed standard immunotherapy.55 If these patients had continued with usual immunotherapy rather than switching to LDA, it could be assumed that the results in the LDA group would have been better than with the standard immunotherapy group.
Lastly, LDA offers the possibility of managing other conditions, including chemical sensitivity or autoimmune conditions.51

Highlights on diagnosis and management of allergies were presented. Immunotherapy is an excellent treatment modality able to induce a change in the dysfunctional immunological system, leading to a cure or at least long-lasting control of the allergic conditions. Different methods of administration have been succinctly described. The value of a safer approach such as SLIT has been underlined. SLIT can be considered for patients with asthma and sometimes in cases where SCIT is considered dangerous or its administration elicited problems. The potential role of LDA for the management of the allergic patient has also been stressed.
Practitioners interested in the management of allergic conditions should consider attending courses offered by mainstream academies (AAOA, AAAI) as well as smaller medical societies such as the Pan American Allergy Society and the American Academy of Environmental Medicine where management of inhalant and food-related allergic conditions, LDA, and other treatment modalities can be learned.

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Dr SaportaDr. Saporta completed his training in 1990 at Columbia Presbyterian Hospital in New York City. He is board certified in otolaryngology and has been a fellow of the American Academy of Otolaryngic Allergy (AAOA) since 2001. His private practice in Elizabeth, New Jersey, is heavily oriented to the management of allergic conditions. Interested in the use of oral vaccines since early in his practice, Dr. Saporta presented a protocol for sublingual immunotherapy at the 64th annual meeting of the AAOA that since then has been successfully used for the management of allergic rhinitis with or without asthma.


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