Non-Allergist Physician Algorithm for Prescribing Allergen Immunotherapy

Background: Allergic rhinitis (AR), affects the health and wellbeing of 20-25% of Canadians, with detrimental effects on sleep quality, cognition, mood, mental health and learning. However, with approximately 1 allergist per 133,000 people, some treatments are inaccessible to allergic Canadians. Current management approaches include avoidance and pharmacotherapy including nasal corticosteroids and nasal or oral antihistamines, while allergen immunotherapy (AIT) offers an effective long-term solution. Sublingual (SLIT) immunotherapy can significantly improve AR and asthma symptoms, reduce allergen sensitivity, modify long-term tolerance and potentially prevent the development of other allergic diseases. Despite clinical efficacy, safety and cost-effectiveness, SLIT is underutilized, partly related to the limited number of specialist allergists available. Given the home administration and safety of SLIT, non-allergists can play a vital role in the delivery of SLIT to the allergic population. Methods: AK conceptualized and developed the initial draft of a treatment algorithm for non-allergists. This algorithm and treatment set was reviewed at an in-person meeting of an expert panel of four family physicians with a special interest in allergic disease and seven allergists. Consensus agreement resolved discrepancies. Results: A focused algorithm with treatment recommendations were developed for non-allergists to diagnose and implement SLIT in the allergic population. This protocol requires accurate diagnosis based on the history of the timing of clinical symptoms, and selected and focused investigations, including skin testing and serum-specific IgE. Patient selection was prioritized with relevant cautions highlighted. With an allergic history and investigations consistent with allergy to dust mite, tree, grass, or ragweed pollen, the initiation of SLIT by non-allergists was encouraged/recommended. An annual review of clinical effectiveness was highlighted; complicated patients or non-responders should be referred for allergist assessment. Future validation and implementation are pending. Conclusion: Safe and effective SLIT treatment for AR can be implemented by non-allergists with a focused algorithm for guidance.