Utilizing Shared-decision Making and Evidence-based Practice for Allergy Immunotherapy

By Karen Rance

Shared decision-making (SDM) is becoming more commonly appreciated and used to empower patients facing treatment preference-sensitive conditions in medical practice. In this age of personalized medicine, this trajectory accelerated during the COVID-19 pandemic where public health was the number one news story every day for two years.

Patients now play a more prominent role in their treatment decisions. With more information available to patients through the internet, patients are equipped to educate themselves about their health better and prepare for office visits with questions and opinions. In a 2018 survey by Carpio-Escalona LV, et al. of 300 patients who attended an allergy clinic, 53% indicated they searched online for information on allergies before their consultation. Personalized medicine depends on a transparent and informative shared decision-making (SDM) exchange being the mainstay between patients and healthcare providers (HCPs). 

As opposed to HCPs making decisions on behalf of patients, shared decisions are gaining increasing prominence in health care policy.SDM has been shown to improve adherence to medications and disease outcomes1. The critical steps of a SDM model include introducing a choice of the available scientific evidence for treatment, describing those options, and helping patients explore preferences and make decisions. Often, this exchange is enhanced by integrating patient decision support aids. One of the most critical aspects of this model is educating patients on an objective and balanced perspective of current clinical research and its relevance to their symptom management and quality of life. Additionally, the model depends on its framework being rooted in evidence-based practice to ensure patients are provided a scientific, non-biased means to participate in their treatment decision-making.  

Allergic rhinitis (AR) is a preference-sensitive condition where the use of SDM, specifically the treatment option of allergy immunotherapy (AIT), is appropriate. AR is one of the most common diseases affecting 10 to 30 percent of the American population, making it the most common chronic disease in children in the United States and the fifth most common chronic disease among adults. AR generates up to $5 billion in direct health expenditures annually. Additionally, it is responsible for a $4 billion annual loss in work productivity. AIT is the only treatment that addresses immune dysfunction underlying allergic responses rather than treating symptoms or suppressing inflammation.  

The available FDA-approved options for AIT include sublingual immunotherapy tablets (SLIT-tablets) and subcutaneous immunotherapy (SCIT), also known as allergy shots. While SCIT has been the cornerstone of AIT treatment in the USA for over 100 years, SLIT tablets gained approval in 2014. SLIT-tablets dissolve under the tongue and are taken once daily at home after the initial dose at the allergy specialist’s office under supervision. SLIT-tablets have established dosing efficacy and safety in mono-sensitized and poly-sensitized patients. Allergy shots, or SCIT, are an exclusively in-office treatment with allergen extracts mixed by an allergy specialist for each patient based on their allergy triggers. SCIT dosing may vary as prescribed by an allergy specialist. Allergy shots begin with weekly doses, and after approximately six to 12 months, the dose is given bi-weekly or monthly. 

Because the patient commitment for AIT is for three years, and treatment adherence to chronic illness medication can be challenging, SDM with AIT patients rises to the top of those treatment plans that are patient-preference sensitive. A 2021 study by Tankersley et al. of 724 adults and 665 caregivers of children with AR underscored the problem with AIT. In this study, both the adults and caregivers had a significant preference for SLIT-tablets compared with both weekly and monthly SCIT injections; however, most experts agree that there is a lack of transparent SDM when discussing AIT treatment choices in the U.S., and patients are largely unaware of the available option for SLIT-tablets.  

A recent study by Stone B, et. al. suggests that doctor-patient conversations play an essential role in AIT use and adherence, including cost and convenience barriers. Because of the distinct characteristics of each FDA-approved form of AIT, educating on the AIT process and reinforcing education must be a focus during each visit. Continuing in the SDM process and listening to concerns may help improve disease management, increase efficiency for allergy specialists and improve health outcomes. In 2018, the American College of Allergy, Asthma, and Immunology, in collaboration with the Allergy & Asthma Network and supported by ALK, published an Allergy Immunotherapy SDM tool/decision aid for patients to help facilitate conversations with their allergy specialist. 

Shared decision-making is a critical component of patient-centered health care. Allergy specialists should work with their patients to reach treatment decisions that align with their values and preferences and optimally treat their disease. Frequently, treatment choices may be presented to the patient in a biased manner, emphasizing the importance of patient advocacy organizations to help inform patients of their treatment options and disease management based on all available evidence. Patients will want time to study new information and consider their personal preferences. Deliberation may, in part, be done outside the clinical encounter, although often, patients wish to consolidate their views with a trusted HCP. Recognizing and allowing time for this need is a cornerstone for effective SDM. 

1 Blaiss M, Steven GC, Bender B, Bukstein DA, Meltzer EO, Winders T. Shared decision making for the allergist. Ann Allergy Asthma Immunol. 2019. doi: 10.1016/j.anai.2018.08.019.