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In 2014, three sublingual allergen immunotherapy tablets have been approved by the FDA: Grastek contains Timothy extract; Oralair contains cross-reacting sweet vernal, orchard, perennial rye, Timothy, and Kentucky blue grass extracts; and Ragwitek contains ragweed extract. These tablets are started 3 to 4 months before, and continued throughout, their pollen seasons; they can be administered at home with very low risk for anaphylaxis.
In an industry-funded, European study, 509 allergic patients were randomized to receive sublingual house dust mite or placebo tablets daily for 1 year; patients were followed for 1 additional year. After 4 months of therapy, the active-treatment group had a mean adjusted symptom score that was about 20% lower than the placebo group's mean score. The dust mite tablets' effects were maintained in the following year with no additional treatment. No patient experienced anaphylaxis, one had difficulty swallowing due to sublingual edema, and about 10% dropped out due to oral irritation.
Bergmann K-C et al. Efficacy and safety of sublingual tablets of house dust mite allergen extracts in adults with allergic rhinitis. J Allergy Clin Immunol 2014 Jun; 133:1608. (http://dx.doi.org/10.1016/j.jaci.2013.11.012)
Comment
The role of sublingual immunotherapy for allergic rhinitis and asthma is evolving. We don't know whether using more than one sublingual extract will reduce effectiveness, so currently, only monotherapy should be prescribed. For patients whose allergies are not controlled with nasal steroids and who have year-round symptoms predominately due to dust mites, I think sublingual tablets will be an attractive home-administered option. However, we will have to wait until we have an FDA-approved tablet, and the likely price tag might make it harder to swallow (currently approved sublingual allergy products cost about US$6 to $8 daily).