Certain things in life you just can't get seem to get enough of--money, chocolate, a Chicago Bears win, and...nice letters from blog readers. An  Italian Allergist recently wrote me in response to my prior blog entries, Why we DON'T need more allergists, and The Allergist:  Odd Man Out.   Here's what he says: 

"I am an Italian allergist and I have read with much interest your reply to the title "we need more allergists" from the ACAAI.   I agree with nearly all your points about the shortcomings of today's allergists, but I think that you are wrong in one point:  the idea that the answer is SLIT.  As you know, SLIT in Europe and particularly in Italy is widely studied, prescribed, and used.  But the problem is that some companies producing SLIT are offering this treatment to general practitioners and family paediatricians, hoping to increase in this way the number of prescriptions.  In Europe in the next years SLIT will be available in the public pharmacies, just like anti-histamines, etc.  In my opinion, and in the opinion of nearly all Italian allergists, we do have to go back to immunological control and immunotherapy, as you correctly state, but in order to differentiate our profession from other specialists the answer is turning to subcutaneous immunotherapy, especially now the new biotechnological products, such as recombinant immunotherapies, are really around the corner.  Congratulations for your site and happy new year!"

Awesome letter.  On several points.  First and foremost, he likes my site, so this means of course he's truly an intelligent and discerning individual.  But beyond that he raises an interesting question--is SLIT truly "the answer" for the allergy profession, when it will be available for seemingly everyone to use--patient, family physician, pediatrician, ENT physician? 

On one hand, we can treat a larger proportion of our patients safely with SLIT, but is this meaningless if we get no referrals because everyone else is doing it?   In a sense, the author poses a large and critical question--The Allergist and immunotherapy:  Quo Vadis?  The author above apparently feels that injection immunotherapy (SCIT) is "the answer", since he states "in order to differentiate our profession from other specialists the answer is turning to subcutaneous immunotherapy, especially now the new biotechnological products, such as recombinant immunotherapies, are really around the corner."  I take exception to this view, for several reasons:

1.  On a practical basis, when SLIT is available over-the-counter, many people will logically use this first, before going to an allergist. If they get relief, they'll stop there.  If they don't get relief, or have side-effects from SLIT, then they'll see an allergist.  Are these "tough cases" the ones we want to put on SCIT, after they've had side-effects from SLIT or not responded?  If they had side-effects from SLIT, they will likely have side-effects from SCIT--probably more severe.  If they didn't get relief with SLIT for (as an example) grass pollen, then they might be unstable and polysensitized, for example, to grass AND mold--again, not an ideal SCIT population to treat. 

2.  It's hard to "market" SCIT to a patient population and emphasize they should see an allergist for it, when there is SLIT available over-the-counter, as the author mentions, in the very near future.  SLIT is just too damn  convenient.  I talked about this in an earlier blog entry when I likened SCIT to "painting" and SLIT to "photography".  We still use both in our society, but one technique is used alot more--because of its ease, convenience, and cost-effectiveness.  (See entry One picture is worth a thousand words:  immunotherapy, painting, and the birth of photography) 

3.  SLIT is more versatile than SCIT.  And it's versatility, like Rodney Dangerfield, just "doesn't get respect".  SCIT just doesn't work for molds, and SLIT does.  SCIT just doesn't work for late-phase reactions, and SLIT does.  SCIT hasn't been shown to work for foods, but there's emerging evidence that SLIT works for foods.  Multiple protocols should be developed for SLIT--and we use these in our office. 

4.  Granted, recombinant immunotherapy is attractive and sexy, but it's way farther back than SLIT for approval--at least in our country. 

The author is truly correct in that--technically speaking-- "SLIT is not the answer".  I'll tell you what is:  Doing SLIT better than everyone else.  And I mean everyone. 

I've used SLIT for 27 years, with multiple protocols--high dose European-style and IDT low dose for late-phase mold allergy.  As times change, I  have increasingly seen patients on SLIT from other practitioners who have failed treatment--and we have to offer them more than SCIT to help them. The "next-generation" allergist better be ready for these patients!   Example 1:  A patient on low-dose SLIT from a practitioner treating her for mold allergy, when her real problem was a moldy home and inadequate SLIT dosing. SCIT wouldn't have helped this patient at all.   IAQ improvement in her home, and higher dose SLIT for molds did.  Example 2:  A patient not getting relief on SLIT from another pracitioner because of an undetected food yeast allergy in a patient who was mold sensitive.   Again, SCIT wouldn't have helped this patient. And SLIT did. 

Finally, It's always risky to differentiate our profession from another by just a technique--and that's all SCIT and SLIT are---techniques.  Tools.  It's not the hammer and nail that make the carpenter, it's the other way around...We not only need to be the best at delivering immunotherapy, but we need to be the best diagnosticians around--for all allergic diseases, not just asthma.  This (I guarantee you) will make patients come knocking at your door.  See my entry "How we can fix it" for more. 

The Allergist, immunotherapy:  Quo Vadis?  The answer to this question will determine the direction of our specialty and its survival in the future. 

Later, Dude