Should I Treat My Allergies With Immunotherapy?

You and your allergist just discussed allergy shots and tablets.

Use this tool to find out more about how allergy immunotherapy might help you treat your allergy and asthma symptoms.

Once you’ve completed the tool, print out the results and share them with your allergist to continue the conversation.

Use the buttons at the bottom of each page to navigate. Let’s get started!

Attention physicians: Visit https://acaai.org/resource/should-i-treat-my-allergies-with-immunotherapy/ to reset the tool for the next patient.

What is shared decision making for immunotherapy?

This shared decision making tool will help you decide next steps in treating your allergies. We’ll describe options, ask questions and work together to figure out the best treatment for you.

The objectives of this process are to:
- Provide information about available treatment options
- Discuss advantages and disadvantages of each treatment
- Help you identify your values and beliefs about the options
- Guide you toward the best possible treatment based on the above

What are your goals of therapy?

The short‐term goal for most patients is to control symptoms. You may want to participate in daily activities without worrying about symptoms or limitations.

Just as important are the long‐term goals:
- Lower the risk of complications in the nose, eyes, sinuses and entire breathing system
- Reduce the risk of sinus, eye, and ear infections that keep coming back
- Shrink the chance of developing asthma, or if you already have asthma, cut back the chance it will get worse over time

Why control your environment and use allergy medication?

The two practices described below are the first line treatment for people with allergies.

Control your environment: One way to control allergies is to reduce the allergens that cause your symptoms.
Use medications that block allergy symptoms: Many chemicals are released in your nose that cause congestion, runny nose, itching and sneezing when you are exposed to an allergen. Medications can give you short‐term relief by blocking these chemicals. They can also be used regularly to reduce inflammation in the nose.

Note: Non‐FDA approved treatments will not be discussed as a treatment in this decision making tool because they have not yet been shown in clinical studies to be safe and effective, and are therefore not covered by insurance plans.

Learn more about common allergens, how to control your environment and the types of medications used to treat allergies.

Treatment Overview
Saline rinses	Decrease nasal inflammation by removing inflammatory byproducts of allergic reactions in the nose
Antihistamines	Block the symptoms due to histamine release ‐ increased nasal drainage, nasal itching and sneezing
Intranasal steroids	Reduce inflammation in the nose and sinuses
Intranasal antihistamines	More effective than antihistamine pills that are taken by mouth
Leukotriene receptor antagonists	Help to reduce inflammation in the nose and sinuses
Oral steroids	Used only for short periods, for severe, intolerable symptoms from inflammation

Saline Rinses	Rinsing the nose with salt water helps reduce inflammation by flushing out the chemicals produced in allergic reactions It can be done with both low‐volume and high‐volume rinses Squirt bottles ‐ small amounts of saline squirted into the nose NeilMed® ‐ high volume (8 ounces) flushed through the nose and sinuses Neti Pot® ‐ high volume (8 ounces) poured into the nose over the sink What to put in: High volume saline can be made with the packets sold for this purpose. Or make your own: Add ½ tsp baking soda to 8 ounces of water Add table salt: ¼ tsp to make a rinse; ¾ tsp to have a decongestant effect How often to do it: Nose sprays will work better if you rinse the nose 30 minutes before using the medicine. Can use up to several times a day whenever helpful. You can’t overdo saline flushes

Saline Rinses

Rinsing the nose with salt water helps reduce inflammation by flushing out the chemicals produced in allergic reactions

It can be done with both low‐volume and high‐volume rinses

Squirt bottles ‐ small amounts of saline squirted into the nose
NeilMed® ‐ high volume (8 ounces) flushed through the nose and sinuses
Neti Pot® ‐ high volume (8 ounces) poured into the nose over the sink

What to put in: High volume saline can be made with the packets sold for this purpose. Or make your own:

Add ½ tsp baking soda to 8 ounces of water
Add table salt: ¼ tsp to make a rinse; ¾ tsp to have a decongestant effect

How often to do it: Nose sprays will work better if you rinse the nose 30 minutes before using the medicine. Can use up to several times a day whenever helpful. You can’t overdo saline flushes

Antihistamines	Work by blocking the action of histamine, the main chemical released in allergic reactions, from causing itching, sneezing and drainage Older antihistamines ‐ diphenydramine (Benadryl®), chlorpheniramine (Chlor‐Trimeton®) Potent; 1‐2 hour onset, shorter duration Often cause bothersome drowsiness; can be too drying Newer (longer‐lasting) antihistamines loratadine (Claritin®), fexofenadine (Allegra®), cetirizine (Zyrtec®), levocetirizine (Xyzal®) Potent; can be used once a day Not effective for congestion, which is usually the most bothersome symptom

Antihistamines

Work by blocking the action of histamine, the main chemical released in allergic reactions, from causing itching, sneezing and drainage

Older antihistamines ‐ diphenydramine (Benadryl®), chlorpheniramine (Chlor‐Trimeton®)

Potent; 1‐2 hour onset, shorter duration
Often cause bothersome drowsiness; can be too drying

Newer (longer‐lasting) antihistamines loratadine (Claritin®), fexofenadine (Allegra®), cetirizine (Zyrtec®), levocetirizine (Xyzal®)

Potent; can be used once a day
Not effective for congestion, which is usually the most bothersome symptom

Intranasal Steroids	Work by counteracting the inflammation caused by allergic reactions. They are the most effective for nasal congestion Liquid sprays are the most common, and are available over the counter except for mometasone (Nasonex®). These include fluticasone proprionate (Flonase®), triamcinolone (Nasacort®), budesonide (Rhinocort®), and fluticasone furoate (Flonase Sensimist®) Aerosol sprays sometimes get up into the nose better. Some people with drippy noses prefer these. They include beclomethasone (Qnasl®) and ciclesonide (Zetonna®) Pros ‐ Very effective for most of the symptoms of allergic rhinitis, and the associated eye symptoms. A good choice for those who want to use only one medicine Cons ‐ Can cause nose bleeds if not used correctly. Controversy over the extent to which long term use might cause cataracts, or a slowdown of growth in children

Intranasal Steroids

Work by counteracting the inflammation caused by allergic reactions. They are the most effective for nasal congestion

Liquid sprays are the most common, and are available over the counter except for mometasone (Nasonex®). These include fluticasone proprionate (Flonase®), triamcinolone (Nasacort®), budesonide (Rhinocort®), and fluticasone furoate (Flonase Sensimist®)

Aerosol sprays sometimes get up into the nose better. Some people with drippy noses prefer these. They include beclomethasone (Qnasl®) and ciclesonide (Zetonna®)

Pros ‐ Very effective for most of the symptoms of allergic rhinitis, and the associated eye symptoms. A good choice for those who want to use only one medicine

Cons ‐ Can cause nose bleeds if not used correctly. Controversy over the extent to which long term use might cause cataracts, or a slowdown of growth in children

Intranasal Antihistamines	The intranasal antihistamines (azelastine [Astepro®], olopatadine [Patanase®]) work the same way the antihistamine tablets do Pros ‐ Much more effective than tablets, since they’re sprayed directly where they need to be. Therefore, a much lower dose than the tablets. Also effective for eye symptoms. Rapid onset, so they can be used when suddenly needed Cons ‐ These are also older antihistamines, and are more prone to cause drowsiness than the newer tablets. Some notice an unpleasant taste if it drips down the throat

Intranasal Antihistamines

The intranasal antihistamines (azelastine [Astepro®], olopatadine [Patanase®]) work the same way the antihistamine tablets do

Pros ‐ Much more effective than tablets, since they’re sprayed directly where they need to be. Therefore, a much lower dose than the tablets. Also effective for eye symptoms. Rapid onset, so they can be used when suddenly needed

Cons ‐ These are also older antihistamines, and are more prone to cause drowsiness than the newer tablets. Some notice an unpleasant taste if it drips down the throat

Leukotriene Receptor Antagonists	Leukotriene receptor antagonists (montelukast [Singulair®]) block the leukotrienes, which are major inflammatory chemicals that are also released in allergic reactions Pros ‐ Easier to take than nasal sprays, since they are tablets. Can help with nasal congestion. Effects are typically modest, but many people see noticeable improvement with them Cons ‐ Not terribly effective for many people. Occasional reports of psychiatric problems such as mood changes or suicidal thoughts in children and adolescents

Leukotriene Receptor Antagonists

Leukotriene receptor antagonists (montelukast [Singulair®]) block the leukotrienes, which are major inflammatory chemicals that are also released in allergic reactions

Pros ‐ Easier to take than nasal sprays, since they are tablets. Can help with nasal congestion. Effects are typically modest, but many people see noticeable improvement with them

Cons ‐ Not terribly effective for many people. Occasional reports of psychiatric problems such as mood changes or suicidal thoughts in children and adolescents

Immunotherapy: Why do it? What is it? How does it work?
- Some people are not satisfied with the symptom control they get with environmental changes and medicines. Others don’t like medication, and prefer to use natural methods such as immunotherapy.
- Immunotherapy gives increasing doses of what you are allergic to (allergen) to build up tolerance by injections under the skin, or by tablets placed under the tongue. Moving forward, we’ll refer to these as “allergy shots” and “allergy tablets”.
- Both allergy shots and tablets work by changing your immune system. They decrease some cells, chemicals, and antibodies in your system that cause allergy symptoms, and increase others that improve health.
- Allergy shots and tablets allow you to come into contact with your allergens without having a reaction.

What are the medical benefits of immunotherapy?

Benefit	Shots	Tablets
Reduces allergy symptoms
Reduces need for allergy medication
Improves quality of life
Decreases chance of asthma
Decreases chance of new allergies
Available for all allergens causing symptoms
Doctor’s office administration of medication
At home administration of medication
Time of treatment	3‐5 years	No clear answer when to stop treatment
Ongoing clinical benefit after treatment	At least 3 years after treatment	1 year after treatment

Your Immunotherapy Options ‐ What’s Involved?

Allergy Shots	Allergy Tablets
Injected in the arm. Afterwards, you’ll wait 30 minutes in your doctor’s office.	Tablet is placed under the tongue. After the first dose in doctor’s office, tablet is given at home daily.
Typically weekly for the first 3‐12 months, then monthly. Most patients see significant benefit within 1‐3 years. A full course of treatment is considered to be 3‐5 years. All grass pollens, tree pollens, weed pollens, mold spores, animal danders (cat, dog, etc.) and house dust mites are available for treatment.	GRASTEK® and ORALAIR® for pasture grasses such as Timothy taken before and during the plant-growing season. GRASTEK® can also be taken year‐round for 3 years.	RAGWITEK® for ragweed taken before and during the plant‐growing season.	ODACTRA™ for house dust mite allergy is given year‐round.
Onset of improvement in one to three years.	Onset of improvement during the first pollen season	Onset of improvement during the first pollen season	Onset of improvement in 8‐14 weeks
Some allergists prescribe an epinephrine auto‐injector in case of a severe allergic reaction.	All patients have an epinephrine auto‐injector in case of a severe allergic reaction.

Considerations and Medical Side Effects of Immunotherapy

Side Effect	Shots	Tablets
Site reactions (red, raised, swollen, itchy)
Cramps, nausea, diarrhea
Very severe allergic reactions	Very rare ‐ 1 in 2.5 million	Extremely rare ‐ 1 in 1 billion

Which Type Of Immunotherapy May Be Best For Me?

Allergy Shots	Allergy Tablets
This treatment may be best for patients who:	This treatment may be best for patients who:
have multiple allergies causing symptoms do not fear needles prefer close observation by their doctor	have a single allergen which causes symptoms fear needles
This treatment may NOT be right for patients who:	This treatment may NOT be right for patients who:
fear needles cannot commit to frequent office visits	have multiple allergens causing symptoms desire closer observation from their doctor

What Does Immunotherapy Cost?

Allergy Shots	Allergy Tablets
The mixtures and injection costs will depend on your insurance plan. Your allergist will mix the injections for your specific allergies. Your allergist can give you billing codes and the quantities you’ll need to check with your insurance carrier to get an accurate idea of your out‐of‐pocket costs.	Tablets are obtained by prescription and cost will depend on your insurance plan. Please check with your insurance carrier to find out if the tablets are covered by your plan and what your monthly co‐pay will be.
Over time, the total cost of care usually decreases because you’ll need less frequent office visits and won’t use as much medication.	Over time, the total cost of care usually decreases because you’ll need less frequent office visits and won’t use as much medication.
You may have to pay the cost of the epinephrine autoinjector depending upon your insurance coverage.	You may have to pay the cost of the epinephrine autoinjector depending upon your insurance coverage.
Studies show the cost of health care for children with nasal symptoms who receive allergy shots was 1/3 less than children who did not have them.

Are you READY?

Lastly, are you READY to begin immunotherapy (IT)?
- Risk‐benefit ‐ Are you clear about the benefits and risks of each option for IT?
- Encouragement ‐ Do you have enough support and advice to make a choice of IT?
- Absolutely sure IT is the best choice for you?
- Duration ‐ Is the schedule and duration of IT clear to you?
- Yes. I am prepared with an epinephrine autoinjector, and know how/when to use it
If you answered No to one or more of these READY questions, be sure to discuss it with your prescriber.

Congratulations!
- We hope we’ve explained your treatment options, together with their benefits and risks in the context of what is important to you
- Please be sure your questions and concerns have been addressed by your provider as you are reaching your final treatment decision
- For reference, click the button below to download a copy of all your responses from throughout the decision‐making tool

Should I Treat My Allergies With Immunotherapy?

Step 1 of 16

You and your allergist just discussed allergy shots and tablets.

What is shared decision making for immunotherapy?

What are your goals of therapy?

Why control your environment and use allergy medication?

Common seasonal allergens:

Common perennial (year‐round) allergens:

Current Approach to Treatment

Immunotherapy: Why do it? What is it? How does it work?

What are the medical benefits of immunotherapy?

My Treatment Preferences

Your Immunotherapy Options ‐ What’s Involved?

Considerations and Medical Side Effects of Immunotherapy

Which Type Of Immunotherapy May Be Best For Me?

Types of Immunotherapy

What Does Immunotherapy Cost?

Types of Immunotherapy

Are you READY?

Congratulations!

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Should I Treat My Allergies With Immunotherapy?

Step 1 of 16

You and your allergist just discussed allergy shots and tablets.

What is shared decision making for immunotherapy?

What are your goals of therapy?

Why control your environment and use allergy medication?

Common Allergens

Environmental Controls

Overview of medical treatment options

Current Approach to Treatment

Immunotherapy: Why do it? What is it? How does it work?

What are the medical benefits of immunotherapy?

My Treatment Preferences

Your Immunotherapy Options ‐ What’s Involved?

Considerations and Medical Side Effects of Immunotherapy

Which Type Of Immunotherapy May Be Best For Me?

Types of Immunotherapy

What Does Immunotherapy Cost?

Types of Immunotherapy

Are you READY?

Congratulations!