Allergists Seek to Bolster Adherence to Shots, Sublingual Drops Treatments

Kerry Dooley Young

September 26, 2022

Two new studies highlight the challenges for patients in sticking with allergy shots or sublingual immunotherapy. Both studies add to arguments in favor of having frank discussions before selecting these options and of making it easier to complete those treatments.

The International Forum of Allergy and Rhinology published two studies by Sandra Lin, MD, of the University of Wisconsin and colleagues that were based on the same search of published literature.

The investigators started with a pool of 1596 abstracts and identified studies on how well people were able to continue with subcutaneous immunotherapy (SCIT) and with sublingual immunotherapy (SLIT).

Sublingual Immunotherapy

For the analysis of SLIT, Lin and colleagues defined "persistence" as continuing therapy and not being lost to follow-up. They defined "adherence" as persistence in accordance with prescribed dose, dosing schedule, and duration. Thirty-two studies met critera for inclusion.

In 26 of the studies, persistence rates ranged from 7.0% to 88.7%, and in 18 studies, adherence rates ranged from 9.6% to 97.0%. The researchers did not conduct a meta-analysis, owing to the great variation in the design of the studies.

Lin and colleagues report that 21 studies surveyed reasons for discontinuing therapy. Ten studies reported that the most common reason for early discontinuation was the inability to take medication according to schedule, owing to forgetting doses or being lost to follow-up. In four studies, treatment-emergent adverse events were the most common reason for discontinuation.

But there were positive findings as well. Eight studies cited symptom improvement during treatment as a reason for premature discontinuation. In one study, 35.4% of patients who discontinued treatment did so because of symptom improvement. In an email exchange, Lin told Medscape Medical News that these articles should remind clinicians that people need assistance in sticking with these therapies.

"I think the main takeaway is that allergy immunotherapy works," she wrote. "But we need to find ways to better remind patients, make the process easier for patients, and figure out possible ways to make scientific advances to possibly shorten the duration of immunotherapy while making sure to have long-lasting symptom relief after discontinuation of therapy."

These articles use the term "adherence," whereas in the past, physicians discussed compliance with treatment. This reflects a shift in clinician thinking. Lin said "compliance" implies that patients are doing as they are told, that they are following orders.

"'Adherence' connotates a positive, active shift in behavior by a patient to follow a regimen to improve their health," she wrote.

Subcutaneous Immunotherapy

From the pool of 1596 abstracts, Lin and colleagues identified 17 articles relevant to their research on adherence to allergy shots.

Fourteen of the studies (82%) reported rates of persistence, which ranged from 16.0% to 93.7%, while seven of the studies (41%) reported adherence rates, which ranged from 15.1% to 99%.

Five studies collected original data on reasons for discontinuing allergy shots. Inconvenience was most cited. Three studies revealed inconvenience and related measures, such as injection frequency, frequency of hospital visits, commuting, and waiting time, among the most common reasons for discontinuation.

Lin told Medscape she conducted this review of published literature after surveying her own patients for a prior study. She wanted to see the "larger picture" of adherence and persistence, she wrote.

These new articles from Lin and colleagues join a broader call for patient support in allergy treatment.

In 2016, French, Italian, Spanish, and German researchers issued "a call to action for improving long-term adherence" with allergy therapies. In their article, which was published in Allergy, Asthma and Clinical Immunology, Pascal Demoly, MD, PhD, of University Hospital of Montpellier, France, and co-authors evaluated strategies used to make it easier for patients to stick with allergy treatments.

These included use of an electronic tablet container with a programmable daily sound alarm for patients taking a timothy-grass-pollen SLIT tablet in Italy. Patients in the test of this approach were randomly assigned in a 1:1 ratio to use the device or not.

After a year, the compliance rate in the device group was nearly the same (91.7 %) as that in the control group (90.3 %), and this difference was not statistically significant, Demoly and colleagues reported.

They cited this in calling for greater emphasis on patient-provider partnerships in allergy treatment, noting that patient engagement has been described as "the blockbuster drug of the century."

"Modern technology enables the interactive, mass dissemination of customized information. However, the application of technology per se is not a panacea for engagement and adherence; 'hi-tech' must be balanced against 'hi-touch' — the maintenance of a close personal connection," Demoly and colleagues wrote.

That personal connection is critical in helping patients get the best results from allergy treatments, Richard F. Lockey, MD, of the University of South Florida, told Medscape.

In his more than 50 years in the field of allergy medicine, Lockey has authored or co-authored over 850 scientific articles, review articles, webpage articles, and book chapters, and he has edited, authored, or co-authored 20 monographs and 19 books, according to an American Academy of Allergy, Asthma and Immunology Foundation profile of his career.

In that time, Lockey has seen what he calls a "revolutionary evolution" in medical science in the field of allergy, leading to a wealth of options for patients, including more effective medications. In some cases, patients with milder allergies do well with these drugs, which also serve well for people with schedules that make them unlikely to stick with allergy shots, he said.

But making these calls involves talking to patients and getting an idea of what commitments they have that might make them poor candidates for allergy immunotherapy, he said. This requires more than the cursory 10-minute visit that physicians and patients often have.

"One of the big problems we have in medicine today is doctor-patient communication, because the doctors are on the computer. They don't have the time to spend with patients, or they don't take the time to spend with patients," Lockey said. "When we put somebody into therapy, we take time to make sure they understand why you're doing it, and when you do that, adherence is pretty good."

The wide variation seen in reported adherence rates that Lin and colleagues found in their study likely reflects how much time different physicians spend talking through the challenges of allergy shots before initiating these therapies, Lockey said.

Physicians need to make sure their patients truly understand the schedules to which they will need to commit themselves and help them realistically assess whether they can stick to these plans, Lockey said.

He said that in his clinic, the adherence rate is very good, likely about 80%, because of the time spent hashing out logistics and getting to know more about patients' lives.

In talking with patients about allergy shots, physicians ask good questions. They need to get a sense of how willing patients will be to stick with these treatments and to check on factors such as whether they have reliable transportation or a calendar packed with business trips.

"We make sure that they don't commit to something they're not going to adhere to," Lockey said.

Int Forum Allergy Rhinol. Published online September 9, 2022. SCIT study, Full text; SLIT study, Full text

Kerry Dooley Young is a freelance journalist based in Miami Beach. She earlier covered health policy and the federal budget for Congressional Quarterly/CQ Roll Call and the pharmaceutical industry and the Food and Drug Administration for Bloomberg. Follow her on Twitter @kdooleyyoung.

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