[00:00:00] Kara: Sick of the fatigue and fog fed up with the unpredictable flares hangry from the super restrictive diets. Hello, and welcome to the crunchy allergist podcast, a podcast empowering those who like me, appreciate both a naturally minded and scientifically grounded approach to health and healing. Hi, I'm your host, Dr. Kara Wada, quadruple board certified pediatric and adult allergy immunology and lifestyle medicine, physician Sjogren's patient and life coach. My recipe for success combines, the anti-inflammatory lifestyle, trusting therapeutic relationships, modern medicine, and mindset to harness our body's ability to heal.
Now, although I might be a physician I'm not your physician. And this podcast is for educational purposes only. Welcome everyone. Thank you so much for joining us this week and welcome to our new listeners. I am so excited today to welcome Dr. Amber Patterson to our episode today. Dr. Patterson is one of my friends and colleagues and mentors who I've known for many years.
We will not say how many years. But we met when I was an allergy fellow over at nationwide children's hospital and she was one of the allergist. who was just a couple of years ahead of me and she was doing some really groundbreaking research at the time on a type of immunotherapy called ILIT, which we're going to talk about today.
And since that time, she has really worked to find a balance with being a mom and a physician and a cutting edge allergist and has a practice now in her hometown and Findlay, Ohio, where she works both with Blanchard valley, the local hospital system, and on this exciting venture called Allergy Unlimited, which we will link to in the show notes.
And talk about later as well. But we are going to talk all about immunotherapy today and what that is. So welcome Dr. Patterson. Thank you.
[00:02:08] Amber: Hello everybody. I'm so excited to be here with you today, and really excited to talk about immunotherapy, which I know you and I both love our passion.
[00:02:18] Kara: Yes, we totally nerd out about it.
So maybe if you don't mind explaining to those of our listeners who are not allergists immunologists, what immunotherapy is.
Sure immunotherapy is. Basically modifying the immune system in a positive way to benefit the patient. So when you have a problem like allergies, the immune system is not working quite right.
So immunotherapy is our way of saying, okay, if you're allergic to dog dander and you love your dog and you don't want to get rid of your dog, but you feel miserable when you're around your dog, we have this amazing. Medical miracle called immunotherapy, where we can expose you to that exact allergen to dog dander over time.
And depending on which type of immunotherapy which we'll get into that later depends on how often or how many treatments you need, but over time, your body gets used to that allergen. And you get to a point where you don't have bothersome symptoms and you don't need medication in most cases, and you can enjoy living with your.
[00:03:28] Amber: That's immunotherapy in a nutshell.
[00:03:30] Kara: Which is pretty darn awesome. And when I think of patients asking me, what are treatments that are natural? What are treatments that treat the root cause? This is it.
[00:03:42] Amber: Oh, absolutely.
[00:03:43] Kara: Yeah. And the other thing that I think people are really, shocked to hear is that this treatment has been around since, before.
Really any of our modern allergy meds have been around for, well over a hundred years, which we're still working out some of the like exact how and why it does this work and refining some of the ways that we do it but known for a long time than it works.
[00:04:12] Amber: Yeah. And that's really exciting in and of itself.
I think it's really fun when you meet with older patients who may be, had immunotherapy 40 years ago as a kid and talking with them just about the history of how it's evolved and how the treatments have advanced. And they're always so happy and excited to know that. Now we have more data on what dose of each extract works well.
And the people that manufacture these extracts can make them more potent in what schedules work best for making sure that not only do you have a safe, effective treatment, but one that's going to last for years after you stopped treatment, because A hundred years ago, we thought you just had to do this forever.
If you had allergies and now we know that you don't. So yeah, it's come a long way and it's been around a long time and it works,
[00:05:03] Kara: Which is pretty. I agree. Like I am fascinated by seeing things over a time in history. And I think one of the challenging things with immunotherapy in general is it does take a long time to study.
It's not necessarily the quickest science to study. It really has taken that amount of time to work out some of the different kinks in this treatment. So why don't we talk a little bit about like run of the mill allergy, immunotherapy as we were taught it the history.
[00:05:36] Amber: So with traditional or conventional allergen, immunotherapy, We take exactly what you're allergic to mix it into a vial two or three, depending on how many allergies you have, depends on how much we can fit in each vile. And you may have. Multiple. And you will get an injection out of a diluted vile, meaning we make it weaker initially so that you can tolerate it because if we gave you the full strength right away, it might be dangerous.
So we diluted down. So it's at a dose that you'll tolerate safely and we give you an injection. And initially that's, maybe once a week, we have various buildup schedules, but most allergists it'll, the traditional schedules once a week. Six 12 months or more. And gradually as you build yourself up, once you get to the full strength, then we space it out most times to about once a month.
And that's where you sit, you get an injection once a month, they take place in your allergist office or sometimes your primary care doctor's office. And you work through that three to five year course. And then deciding when to stop. It is a decision between you and your allergist. And there, that's probably a whole separate discussion, but some people, three years is all they need some need a couple more years.
I'd say it's a small percentage, rare that ended up needing to go back on it after they stop and they continue it. And there's probably a small percentage on the front end that it doesn't work all that well for them. And we know that within a year and then we stop it. But the majority of people, three to five years of the.
Routine maintenance treatment. We'll get them feeling really well. Few allergy symptoms, if any, and most of the time off of their maintenance medications.
[00:07:26] Kara: Which I think always, really just gratifying to have the ability not to like, I think there's this perception and we hear like very often that we're pill pushers and that, we're just trying to put people on medications and medications are band-aid.
And so to have this treatment option that really can help switch the immune response from fighting to ignoring it's just really fun and exciting. And I think I'm also just feeling extra jazzed because. I am around my fifth year of being an attending. And so we weren't going to talk about timeframe, but it's those patients that really I've started on treatment early, either as a fellow or early as an attending that have been seeing this benefit, and I'm starting to have those conversations with them. And I actually did yesterday and on Wednesday too, of okay, are we ready to stop
[00:08:21] Amber: Yeah, that is a really exciting time point because you're. Seeing the end of the fruit of all your labors and they're seeing it too. I think another fun thing is every once in a while, I'll get somebody who maybe forgets how bad they were. And I love going back in the notes and saying, oh, Hey, do you remember the first time you came?
And you told me that your eyelids puffed up so much, you could barely see and your nose was so runny, whatever. That just seeing the look on their face oh my gosh, you're right. That doesn't happen anymore. And it's just gratifying on both sides to know that we're really helping people change their lives for the better.
And with that being said, that's probably the number one thing I hear patients say after a course of immunotherapy, you have changed my life.
[00:09:08] Kara: That's why I like life coaching too. Like it's feeling of making a huge momentous change and to help someone feel better and live their best life.
Like same idea. And I guess one thing probably good to mention, we've been talking about immunotherapy's role in treatment of allergies, but it's actually approved to treat more than just run of the mill allergies. So certainly can be helpful for your runny nose, itching, sneezing but also is approved and shown to be effective in treatment.
For some people allergic eczema or allergic atopic dermatitis in certain instances asthma and there's some data to say that it can help prevent. The development of allergic asthma, especially if we're thinking about it in kids. And we also will use it for venom or stinging insect allergy. So bee stings wasps, Hornets, fire ants, all those sorts of things.
[00:10:06] Amber: That's a good clarification. And for anyone that's heard of (OIT) oral immunotherapy, that's usually used for food and that's a totally separate thing from what we're talking about right now.
[00:10:17] Kara: Also really cool and reminds me that I should invite one of our colleagues doing that on the podcast.
So we can talk through some of how that works and some of the myths and misperceptions too.
That what we were talking about were allergy shots, what you maybe have had, or have talked with friends or family or classmates growing up, doing that. But something that Amber and I share that we offer in our practices is something called sublingual immunotherapy. Sub meaning under, lingual meaning the tongue.
And so these are treatments that go under the tongue. So maybe we can talk a little bit about how that differs.
[00:10:56] Amber: Yeah. So one of the things about allergy shots. Is that it does require a time commitment. So like I mentioned before, if you want to do allergy shots, you have to get them in a medical office setting.
We talked about how immunotherapy has changed over the years and decades ago. Sometimes people were allowed to do their shots at home, but for safety reasons over time, That's been reigned in and that's no longer recommended for most people. We definitely have patients that could benefit from immunotherapy or allergy shots.
But they don't do it because they cannot commit to the time they can't get into my office every week, or they don't want to they want to spend their time doing other things. So sublingual immunotherapy has an advantage in that after tolerating, the first dose in our office. The patient can do it at home.
And it's something that they do every day. So like a daily medicine, but it's allergen extract. It's not medicine. So it's natural extracts and similar timeframe to allergy shots, like three to five years. And it's just that gradual shift in the immune response over time.
[00:12:10] Kara: And the other place where I've seen it, be really helpful.
I have quite a few patients who like myself, don't like needles. And so if there is a lot of needle phobia or anxiety with coming into the office, like that's another way that we can think about having kind of access to this treatment option without without that. You know that issue at play?
I think one of the things I expected to see though, when I looked at the science and kind of some of the research around sublingual immunotherapy was for. Many people, coming into the office is a barrier to care. And so this eliminates one of those barriers, but we also know it's hard sometimes for certain people to take something on a daily basis.
So I thought, for sure, like when I looked at the literature that there would be a lot, like much better adherence or, patients sticking with the program with sublingual compared to shot. But it's actually pretty equal.
[00:13:15] Amber: It is. Isn't that funny? Like human nature.
Yeah. And I think it just goes to show that you really need to personalize like this treatment to like what works for each person, because for some people having an appointment on the calendar is like sacred.
And so for them like that, that, coming in for shots works and for other people, like they're really diligent about taking their daily anti-histamines so swapping that out or, adding in drops and then taking away the tablet, like that's really easy for them to and so this is where, like this idea of.
Personalization is really important. And also realizing that three to five year commitment is also really challenging. So that is something I think, as allergists we've been looking for the better mouse trap.
When we think about sublingual, I think one of the other things that comes up and my discussions with patients is, this is a treatment that in the way that you and I are practicing it and talking about is considered off label from the FDA. And so probably at least worth mentioning about that and what that means.
Do you want to explain what that means?
[00:14:32] Kara: Yeah the FDA essentially Has approved allergy shots.
And when allergy shots were researched and approved, it was a different timeframe for how that approval was obtained. And essentially there are a couple of types of sublingual immunotherapy that are tablet forum that are FDA approved. It's really hard to make the case to the companies that make our extracts to go through the process of getting FDA approval for these liquid drops or these allergy drops because there's really no financial incentive for them to do it.
The only difference that may happen. From the consumer side or the patient side, as they may see the potential for insurance coverage, but also maybe not because we're not seeing coverage for these FDA approved tablet. All that often either. So the tablets that are available, I'm going a little bit all over the place, but the tablets that are available for grasp pollen.
There's two products that are approved for that. And then there also is a product for ragweed, which is a falltime allergen and then dust mite, which is a year round allergen. Those are. Available by prescription typically prescribed by an allergist though, and maybe in some parts of the country by primary care docs is, or ENT is as well.
And those tablets start off typically start off at the top dose and you just stay at that same dose. In those studies, a lot of patients had a lot of like mouth itching, throat irritation, mild swelling in the mouth. And that was in two thirds to three quarters of patients. And does make it challenging to want to stick with the treatment regimen when you're having all of those side effects.
So one of the advantages I think we probably would say with our liquid formulation is that we're able to like with shots, dilute it down a little bit and do a little bit more of an escalation to minimize those side effects with starting off treatment.
[00:16:43] Amber: Sure. And make it more personalized, like you said.
Yeah. So I guess just to summarize, so the extracts that we use for the slit drops is the same natural extracts that are FDA approved for being injected under the skin for allergy shots. It's just being put under the tongue and the dose is based off. Hundreds, if not thousands of studies that have been done over the years in the US and Europe in Mexico there's a lot of data showing, did I leave something out?
[00:17:14] Kara: I just said Japan too. I know, I like say a lot of stuff, too.
[00:17:18] Amber: Oh yeah. You're right, Asia. We're probably, there's probably every continent that has academic centers studying has been studied and shows that it works. So it's just The companies that make them just don't want to go through the hoops to approve them for putting it under the tongue, but it's still the same stuff.
[00:17:36] Kara: Yeah. Because they already have it approved to go under the skin and it doesn't benefit them in any way really, because we're still buying them to do it in this way without that approval.
[00:17:48] Amber: Sure.
[00:17:48] Kara: Yeah. And for the patient, the difference is that. You have the potential to have your allergy shots, maybe partially, or to some degree covered by insurance.
The allergy drops as a rule are not covered, but the out-of-pocket costs for many of my patients are not really any different.
[00:18:13] Amber: That's what I've found as well. That when you look at what insurance is actually covering. Unless you have some kind of golden insurance policy that you're probably going to be paying about the same.
[00:18:26] Kara: Okay. So this is a good segue into something that you're doing that I'm not doing, that I am totally. Fan girling which is called intro lymphatic immunotherapy. So maybe you could dive into that for us.
[00:18:42] Amber: Sure. So interlock biotic immunotherapy or ILIT, I-L-I-T is the newest form of allergen immunotherapy available and similar to the slit drops.
It uses off label of the FDA approved extra. And with this method of immunotherapy, we drastically reduced treatment time. So we take the allergens that we're treating. We are able to use a much lower dose than the maintenance dose of the other forms of allergen immunotherapy. And we inject this directly into a superficial lymph node with ultrasound guidance.
So in essence, we're taking. The extract that with traditional allergy shots would be put under your skin and then your immune cells would transport that to the closest lymph nodes or with slit, we're putting it under the tongue and your body's transporting that to the lymph node. We're just handing it to those cells in the lymph node on a silver platter with a bell on top and they can do what they need to do.
And we're also bypassing a big part of the immune system that can cause a serious allergic reaction. Because we're administering this directly in the lymph node, we are able to do three injections each one, four weeks apart. So one injection. Four weeks later, another four weeks later, another, so over eight weeks, we can do a complete treatment that in essence gets you similar efficacy based on studies that have been done to a full course of traditional allergy shots.
[00:20:24] Kara: I E that three to five years.
[00:20:26] Amber: Yes. So takes three to five years down to eight weeks. Mind blown.
[00:20:32] Kara: Yes. And gets rid of pretty much gets rid of the risk of anaphylaxis, which is. Biggest worry with allergy shots, little less worry. Quite a bit less worried with sublingual, too.
[00:20:45] Amber: Yeah. Definitely decreases that risk.
So it's so cool. When you think about options for patients, we talked about. The skin subcutaneous or the traditional allergy shots, the sublingual drops. And then now islet, it's there's something for everybody, like you take the pros of one thing and it helps counteract the cons of the other with islet, it's the people that really value time that's for them.
If you don't like needles, slips for you, if you're more of a traditionalist and you've got great. Maybe you're doing the traditional allergy shots, but it gives people options to help them get better. And in the case of islet to get better, faster, because we know that once you complete that full eight week course within three months, you're going to start feeling better.
So it's very exciting times for people with allergies.
[00:21:39] Kara: And so I think people might get a little bit nervous when they hear about ultrasound, lymph node. Like I think, probably what comes to mind is thinking, some of these I think usually when you hear or talk about lymph nodes, it's like the idea of a biopsy, or those sorts of things.
But can you explain what that actually looks like? Cause it's really not that not as big of a deal as people would I think be imagining.
[00:22:05] Amber: Yeah. So we have lymph nodes all throughout our body. But there's one place that they're really, while they're probably two places that they're close to the surface, but the easiest to get to is in the inguinal region.
And I like to describe that as the top of the leg or the bottom of the hip it's in the groin region, but it's super easy to get to most people that are undergoing this procedure. If they come into the office in shorts, they can just kinda hike up their shorts on one side, of course, you're in a private room and you're covered, but it's not like anything that out of the ordinary really.
[00:22:42] Kara: It's just under the skin.
[00:22:43] Amber: Oh, you can, a lot of times you can even feel it. It's just there. And. I was going to say something about pain, but before I do that, I just wanted to mention when I was first developing the clinical trial protocol, that was one of the questions just of the people I was bouncing ideas off of.
They were like, who's going to want you to go in the groin area. That sounds weird, but like you said, it's actually, it's not that bad in that study. And we treat. Pediatric patients, we treated adult patients in that study and everybody that signed up for the study, like that wasn't even an issue for them or a question.
So yeah, there's that, but regarding pain
[00:23:21] Kara: Or lack thereof.
[00:23:22] Amber: Yes. So in the Sentinel islet study done by Thomas Kundig and his crew in Switzerland. That was part of the study was looking at pain of an intralymphatic injection compared to an Ivy stick. So if you had to get labs drawn or something, and the intralymphatic injection was virtually painless.
And when you think about it, it's a small needle going just through the skin, which is where the nerves are. But once you're through the skin, you don't really feel anything. There aren't nerves in the lymph nodes. So it's just through the skin. Boom. And virtually painless for most people. So that's really exciting.
Sometimes with traditional allergy shots, like the actual shot itself is similar. It doesn't really hurt much at all, but because sometimes we're administering a larger volume and it's right there. Sometimes that gets a little stretching and little discomfort, which we can easily manage. But comparatively the lymph node injection is not very painful at all.
[00:24:27] Kara: Do, and this is something that I am not practicing it. Do patients sometimes get like a little swelling of that lymph node? Like you would with a cold, or sometimes you feel a little like lumber bump or not really.
[00:24:40] Amber: So it's more just the volume that you're injecting. I've had patients describe it as.
I just feel the pressure that, you pushed when you push that in, I could feel it expanding a little bit of pressure, but not really in sometimes you'll get just a little tiny, like mosquito bite on the skin above it, but you don't tend to get a large local reactions that some of our shot patients get.
[00:25:07] Kara: And how about like in the days or weeks following, like between those injections? People just do their thing.
[00:25:14] Amber: Yeah. Usually if there is any, like most of the time, there's nothing like after the injection, they don't feel anything. You don't see anything. And if there is usually within 24, at most 48 hours, that's all resolved.
So they just go on about their business. It doesn't affect their ability to walk or do anything.
[00:25:35] Kara: Do you have any, I like idea about. I know that this treatment is not widely available yet, but any ideas on like how people may look to find someone like ABI, of course, we want to send people your way, but maybe to Ohio isn't like feasible.
Do you have your finger on the pulse?
[00:26:01] Amber: Yeah, so we're actually in the process of setting up a network of allergists who are like-minded and want to be able to offer this to their patients. So my goal is to then be able to have those docs on our website. So if you go to allergy unlimited.com. Right now it's not there, but we're working on it actively.
And hopefully there will then be a page where you can find other providers that are offering this.
[00:26:26] Kara: And that kind of have that knowledge base.
[00:26:29] Amber: Exactly. That they've been properly trained and they know how to do it, and they know how to dose it.
[00:26:34] Kara: Yes, that sounds good. And from what you've told me, Finley is an awesome place to visit and to live. So it would be three visits, three.
[00:26:47] Amber: Exactly. And we have people that fly in or drive in from all over the place. And that's exactly what they say. They're like, you know what, it's only three visits. I want to feel better fast.
And let's do it.
[00:27:00] Kara: Yup. Yeah. So we've mentioned, but your website is allergyunlimited.com. So that's where people can go check out. What I really appreciate is it's so transparent. That's a really nice thing I think about as we think about different models of care and. And trying to design like a better system, because we know obviously the medical system is far from perfect.
But and I don't know exactly what that answer is, but I think transparency is really something that we all crave on all sides of the issue. And I know in my day to day practice, And in dealing with insurance, it is the it's as clear as mud. So that I think is one advantage. If you are thinking about embarking on some of these treatments that are considered off label or not covered by insurance, then one of the nice trade-offs is that there is increased transparency.
[00:28:07] Amber: Right from the get, go with the cost is going to be an I think of it like dental braces, like so many people are used to just paying for dental braces if they don't have dental insurance, or if, if you're over 18 and you want dental braces, usually they're not covered by insurance.
And it's just a part of our culture. A lot of people want to do it, so they just figure out how to make it happen. And this is the same thing. So from the beginning, I wanted to make sure that pricing was very transparent so that people can make up their own minds. And there's no like hidden surprises.
That's just the cost is the cost.
[00:28:44] Kara: Yep. And overall I would have to say, just thinking about what we charged for sublingual and, or. What I hear patients like having to pay out-of-pocket for shots over the course of three to five years, it's gotta be equal if not less expensive.
[00:29:05] Amber: So I think in a lot of cases that's true.
[00:29:07] Kara: Including gas and time.
[00:29:10] Amber: Yes. Time is the big one. What are you worth?
[00:29:15] Kara: Oh my gosh. Yes. Yeah. Oh, this is so exciting. I needed to teach me all of your ways. And I'm just really excited to see this growth too, from knowing you when you were doing kind of that. You were the first person to study this in pediatrics in the world.
So I probably should have included that in your introduction and like to see this now coming to market and being able to offer it widely is just super inspiring and incredible. And. It really is a huge game changer in what we've seen in immunotherapy. And so I am, like I said, I'm totally fan girling.
So everyone should go check out allergyunlimited.com. Check out what Dr. Patterson is doing. You can find all the information there to schedule. If someone wanted to schedule an appointment with you. Correct. And do you do virtual consultations? I'm trying to remember how that was working.
Like if someone were out of state.
[00:30:17] Amber: So how it typically works. You do have to end up coming for the procedure. One of our staff members will get on the phone to do just to okay, what are all the logistics here? What are we going to need? Gather any documents. And that way your trip here is fruitful.
And then in the office, we can do the consultation and review the labs and do any, specific testing. If we need to repeat anything. Do the first treatment that same day.
[00:30:44] Kara: Awesome.
[00:30:45] Amber: Yeah, in Ohio, we could definitely do a virtual as a first time.
[00:30:49] Kara: And I'm curious, like I go stuff everything's been very rapidly changing in our COVID times.
Yup. That's super cool. And just really makes it that personalized, super easy experience for the patient.
[00:31:06] Amber: That's what we're trying to do. Easy allergy relief.
[00:31:10] Kara: Yay. All right. Thank you so much. And we will have to talk again soon and thank you everyone for joining us today and look forward to talking with you again next week.
[00:31:23] Amber: Thanks for having me.
[00:31:24] Kara: Thanks for listening to the crunchy allergists podcast with me, your host, Dr. Kara WADA and our guest this week, Dr. Amber Patterson, we hope you enjoyed our deep dive into allergy immunotherapy. If you're keen to learn more about how to manage your misbehaving immune system with a naturally minded and scientifically grounded approach, you can head over to crunchyallergist.com.
Join our email newsletter list, as well as check out the links and resources in the show notes. That's all for this episode folks. See you this time again. Next week. Take care. .
