The traditional way to do immunotherapy ‐ still in use since 1911 ‐ is to give injections weekly for the first year. Since we are injecting the things to which you’re allergic, we have to start at very low doses, so you don’t have a severe reaction to the injections. However, we can’t eliminate the risk of a severe reaction, so the injections must be given in a medical office equipped to treat severe reactions. We gradually increase the dose so that by the end of the first year, the dose is so high that you have substantially lower reactivity and we can space out the injections to once a month.

All of the studies of immunotherapy have shown that it is best to continue these monthly injections until you have been on immunotherapy for a total of five years to get the maximum benefit. People who have received allergy shots for at least five years have been shown to have the longest‐lasting benefit from the shots after they stop.

Cluster immunotherapy consists of four 2.5 hour visits over the first two weeks. You’ll receive up to four sets of injections in the first 1.5 hours, and we observe you for another hour to make sure you don’t have a severe reaction. Since we’re stepping up the dose so rapidly, we provide you with medications to take the night before and the morning of each cluster to reduce the risk of a severe reaction. The way we increase the dose has been shown to be well tolerated in most people, but some patients cannot tolerate the rapid buildup and need to finish it with the weekly injections.

However, for the vast majority of people that complete all four clusters, those four clusters over two weeks get through as much buildup as 31 weekly injections, so we cut off about seven months of the weekly trips into the office. We can’t eliminate the weekly trips with the clusters since building up all the way to the maintenance dose that rapidly would create unacceptable risk. Therefore, there are still twelve weekly injections to get to the maintenance dose after the clusters are completed. However, the buildup to maintenance with cluster immunotherapy takes a total of 14 weeks, as opposed to 48 weeks with traditional immunotherapy.

Sublingual tablets are currently approved in the United States for grass and ragweed pollen, as well as dust mite allergy. Placing the allergen into the mouth doesn’t give the immune system the same exposure as when we inject it under the skin like traditional or cluster immunotherapy. As a result, oral immunotherapy tends not to work quite as well as shots. However, the risk of severe reactions to the tablets is much lower, so they are approved for use at home. Even though tablets have to be taken daily instead of weekly, it is a lot easier to stay on track with treatment when doing it at home. The only restriction is that since the exposure to the immune system is through the lining of the mouth, we ask you to not eat or drink anything for 10 to 15 minutes after putting the tablet under the tongue. This allows the allergens to get absorbed, rather than rinsing them away.

The tablets are generally covered by insurance, but it is not typical for most insurances to cover more than one tablet at a time since that would be substantially more expensive than injection immunotherapy. Therefore, the tablets are most appropriate for people who are allergic to only one of these three allergens. Additionally, some patients with multiple allergies find that medications control their symptoms well enough except for when they are exposed to just one of grass, ragweed or dust mite allergens. In those cases, patients may receive benefit from taking one tablet and continuing to use medication for their other allergies.