Seventy-five percent of patients seen by an allergist are polysensitized (i.e. they are allergic to more than 1 allergen). The best therapy for polysensitized patients is allergy shots, also known as SCIT (subcutaneous immunotherapy), since we can put everything you are allergic into your shots. In order to give therapeutic doses, you will be on 1 to 4 shots depending on how many things you are allergic. The second big advantage of shots is that you eventually only have to come in for your shots once a month. The shots start working about 3 months after reaching your maintenance dose. However, shots may not be the best option for you if you can't stand the thought of needles or your current schedule doesn't allow you to come into the clinic to get the shots.
The big advantages of "the tablet", also known as SLIT (sublingual immunotherapy) are 1) convenience since the tablet can be taken at home, 2) there is no build-up dosing so improvement is seen as early as 8-12 weeks and 3) safety which is why the tablet can be administered outside the clinic. There has never been a fatality associated with SLIT anywhere in the world. There are four FDA-approved SLIT tablet products (ODACTRA for house dust mite, GRASTEK for Timothy grass, RAGWITEK for ragweed and ORALAIR for northern grasses). SLIT drops are not FDA-approved, not recommended by the American Academy or American College of Allergy, Asthma and Immunology and typically given in the US in placebo doses based on scientific studies. The Tankersley Clinic only offers SLIT tablets for these three reasons.
The two main disadvantages of allergy shots is 1) inconvenience since you have to come in 1-2 times per week for a total of 30-40 visits before you can spread your shots out to once a month and 2) risk since we are injecting you with what you allergic and you could have an allergic reaction. Although 98% of patients never have a systemic reaction, severe reactions can occur and can be fatal. Historically there are two deaths per year in the US from anaphylaxis related to allergy shots. This is rare compared to driving in a car. There are, sadly, 100 deaths every single day in the US in car accidents but you don't ride a horse to get around, right? You don't drive crazy and we don't do crazy things with allergy shots. There are benefits and risks in everything we do. We screen you before putting you on allergy shots, screen you every time you get your shots, and build you up nice and slow to the maintenance dose. We require you to not only receive your shots in our office but also to wait in our waiting room for 30 minutes as 90% of severe reactions occur in the first 30 minutes following an allergy shot. We follow national recommendations on site administration and wait time for allergy shots. Your safety is our #1 priority. If your allergist does not make you wait in the waiting room after your shots or allows you to give your shots at home, it's possible there's very little allergen in your shots and any improvement you've received is from the "placebo effect". See the below article, "When Allergy Shots Don't Work".
When we make your allergy kit, we make four vials for every shot you receive. Each vial is 10 times stronger than the one before it and each is color coded starting with a green vial (green means go), then blue, then yellow and then the red maintenance vial (red means stop). We give increasing doses at every visit in 0.05 mL increments starting at 0.05 mL and building up to 0.5 mL with 10 injections from each vial. Ten injections from each of the four vials means there are 40 visits to build-up to the maintenance dose. The first dose you receive is 1/10,000 of the final maintenance dose. Once you reach the maintenance dose, you only have to come in for your shot(s) every 4 weeks. Once a year we have to make a new maintenance vial when it expires. The red vial has an expiration date of 12 months. Due to potency differences, we cut your dose 50% when you receive the first dose from the new maintenance vial then you build back up to maintenance over 5 more visits before going back out to once monthly injection visits.
We offer cluster immunotherapy. What is cluster? Cluster is where you get your shot(s), wait your 30 minutes and then, instead of leaving, we give you your next visit's shot(s) and you wait another 30 minutes. Thus, you knock out two visits in one which saves you the back and forth to our office. Your insurance will typically dictate whether cluster is a good option for you. Our patients who do cluster love the convenience of getting through the first 20 visits in only 10 visits. The sooner you get to maintenance, the sooner you get to move out to every 4 weeks and the sooner you will get improvement in your symptoms. We schedule shot visits so that we know when you are coming. Our commitment to you is to get you in and out of our clinic as fast as possible, we just can't compress the 30 minute wait time. Let us know if we're not doing a good job of this as we value your time and know you make a big commitment to go on allergy shots.
Once you start immunotherapy, Dr. Tankersley will see you back in 1 month to monitor your medications and build-up schedule on shots. He will then see you back 2 months later, then 4 months later then every 6 months while you continue on your shots. A full course of therapy is typically 5 years. You don't gain anything significant after 5 years by staying on shots and don't lose anything by stopping. Any symptom recurrence would be 2-4 years after stopping therapy after a 5 year course. You can find additional information about immunotherapy on our Resources page.
Allergy kit: the first injection is from the green vial and patients are built up to the red vial.
Green means GO! The green vial is the weakest of the 4 vials. Your first dose will be 1/10,000 the strength of your final dose. We will slowly build you up over 40 injections to the maintenance dose. Cluster visits get you there faster!
You are 25% of the way there! You'll get another 10 injections from the blue vial. You can do cluster injections through this vial also.
You're half-way through the build-up phase! Just like the first 2 vials, we'll increase your dose by 0.05 mL at each visit. You're doing great!
Red means STOP! You made it to the maintenance vial! You'll still have to build-up from 0.05 mL to the maintenance dose of 0.5 mL. Once you get to 0.5 mL, you only have to come in every 4 weeks! We'll make a new maintenance vial once a year.
You can come in up to twice a week but never two days in a row. If you miss a week, no big deal! Enjoy your European vacation! You can go up to 14 days between visits and we can still advance the dose. Breaks >14 days require dose adjustments.
There's a big placebo effect with IT, i.e. allergy shots or immunotherapy. The effective dose is reached in the red vial. Symptom improvement from the shots will begin 8-12 weeks after getting to your maintenance dose. You'll stay on your nasal sprays initially but our eventual goal is to get you off the meds!
Claritin, Clarinex, Zyrtec, Xyzal, Allegra, Nasonex, Flonase, Astelin and Singulair. All treat allergy symptoms, but none actually makes you less allergic. You stop the medicine, it soon stops working. Allergy shots are unique in that if taken at the right dose for 3-5 years, they can continue to provide beneficial immunologic effects after you stop taking them. In short, allergies shots offer a potential cure to your allergies with 80% of patients getting an 80% improvement.
Frequently, though, people say allergy shots don't work. Why is that? Most likely, it's an inadequate dose. To a point, the higher the dose, the better the protection it gives you. Ask your allergist, "How many micrograms of Der p 1 does my maintenance dose for dust mites contain?" Higher doses are associated with increased side effects, but most reactions are mild—itchy arms, local swelling. Taking antihistamine before you get your shots or applying ice to the site of the shots usually works. Rarely, high effective doses of allergy shots can cause serious reactions—wheezing, hives all over, even anaphylaxis. That's why we follow national guidelines and monitor each patient for 30 minutes in our clinic after each shot. If you are being allowed to take your allergy shots at home, it's possible that there is very little allergen in your shots and most of your improvement is what we call "a placebo effect". Of note, 50% of patients on placebo shots say they felt better. There's a strong placebo effect with allergy shots.
Why else don't allergy shots work? It's important to split up some components into separate vials. For example, mold and allergens can destroy tree, grass and weed allergens in the same vial making them ineffective. If you are allergic to several things, but your allergy serum is all in just one vial, it is possible that some of its contents are being degraded. Molds should be in a vial all by themselves. There is enormous variability in how allergy shots are formulated, and how they are dosed. Many allergists continue to follow recommendations made 30 or 40 years ago.
At The Tankersley Clinic, we base our allergy shot doses on the most recent national guidelines published by the American Academy and the American College of Allergy, Asthma and Immunology. The doses we use are doses that are recommended based on scientific research and national recommendations. Some people call this "standard of care". We are shooting for a cure with the doses we use. If we don't get a cure, we won't be accused of not using appropriate doses. Maybe that is why we hear, "these shots have changed my life" more often than "these allergy shots don't work."
We don't want you to just run the race, we want you to win the race!
As recently as 20-30 years ago, allergy shots were very different. In 2003, clearly defined immunotherapy ("allergy shots") practice parameters were published by the American Academy and American College of Asthma, Allergy and Immunology. They were updated in 2007, and again in 2010. The Tankersley Clinic follows these guidelines as a part of our core values of integrity, service before self and excellence in all that we do.
Now, with cluster visits, we are able to make allergy shots work to block your symptoms within half the time as usual. More importantly, we are often able to stop your allergy shots after three to five years and have the immunologic benefit continue thereafter.
The beauty of being an American is having access to the freedoms that we have. Dr. Tankersley served our country as an Air Force allergist for 22 years so he especially knows the value of the freedoms we have in the United States. However, this sometimes means that things are less regulated in some areas. This is especially true of allergy as you don't have to be a board-certified allergist to practice allergy in the US. Anyone can open a "allergy clinic" and call themselves an allergist. Unfortunately, there are some providers in the US that continue to provide the same allergy shots they did 50 years ago. If you don't have to wait 30 minutes or if you're allowed to take allergy shots at home, it's possible you are on placebo shots. Both of these practices are not recommended by national practice parameters. Ask your allergist if the doses they use in your shots are the same doses recommended in the national practice parameters. If you had a headache as an adult, would you want 80 mg of Tylenol or two extra-strength Tylenol? An 80 mg dose would not be an effective dose. In the same way, there are dose ranges for allergy shots and low doses are not effective doses. The family practitioners, internists, pediatricians and ENT doctors who send their allergy patients to The Tankersley Clinic don't do their own allergy, because they want their patients to get the best allergy care from a board-certified allergist that follows national guidelines and always uses allergy shot doses in the effective range. We don't do placebo dose immunotherapy at The Tankersley Clinic. For every patient, every dose is the right dose, at the right time, and in the right location.
The bottom line is that we base our allergy shot contents on current scientific research. Those in the US who use placebo doses base their recipes on tradition; still practicing the same methods that were used 50 years ago. Study after study has shown that these obsolete techniques are no more effective than a placebo (sugar pill).
Did you quit taking allergy shots because they just didn't work? Unlike nose sprays and pills, wouldn't it be great to achieve the unique benefit that only allergen immunotherapy provides? Maybe it's time to try allergy shots again. But this time, leave it to Dr. Tankersley at The Tankersley Clinic who uses doses that are based on science rather than tradition. We serve the allergy, respiratory and skin care of needs of those in Memphis and the Mid-South.
We don't want you to just finish, we want you to finish first!
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