Hey there all you mouseketeers...it's time for the Second Annual Allergist Poster Contest...even though it's 8 months early.  Why, you ask?  Easy. 

Because I said so.  

The First Annual Allergist Poster Contest was such a success we just had to repeat it sooner than 12 months.  And besides, there was no clear winner in our first contest.   Too many readers thought all 3 posters were equally good.  So I've had the CRAP (Committee Regarding Allergy Posters) working hard on another entry.  Meanwhile, I've been busy trying to find out where all the American Papers on Sublingual Immunotherapy are...turns out they're harder to find than O.J.'s knife...

True, we've got one nice but lonely American nice study from--you guessed it--our ENT colleagues in Ear Nose & Throat by Saporta & McDaniel , and a host of international studies--but where are our American Studies sponsored and supported by our American allergy academia?    I mean, if you look at the literature for 2007 alone, you will find more non-American SLIT studies than you can shake a caduceus at--from Antony, France; Turin,Italy; Melbourne, Australia; Murcia, Spain; Vienna,Austria; Istanbul, Turkey; Turku, Finland; Madrid, Spain; Messina, Italy; Como, Italy; Bari, Italy; Hoersholm, Denmark etc. etc. etc. We American Allergists are so busy demonstrating proper inhaler technique to our asthma patients we forget to study what we do best--immunotherapy.  And we ignore a particular form of immunotherapy that just plain rocks:  SLIT...

Earth calling all American Allergists--come in, please.  

Houston, we have a problem... 

So this year, our poster is set to epitomize the American Allergists interest in researching Sublingual Immunotherapy for ourselves...after all, if American Allergists are not just paying "lip service" to our European colleagues when they say they agree they've shown efficacy and safety for SLIT, then there ought to be a TON of research churned out by the Ivory Tower Types on SLIT from American institutions, right?  I mean we should see articles every other issue or so in the major allergy journals from American allergists investigating various forms/regimens of SLIT. 

Well, Gladstone, they ain't there.  

So, here's where I slap on another "Black Box Warning" for you faint-of-hearts, before I formally announce the official finalists in the Second Annual Allergist Poster contest--a contest to epitomize and symbolize the American Allergists interest in SLIT.  Here goes:

OK, those of you brave but curious souls who have read and accept the Black Box Warning to the left, you can see the finalists listed below, and I have to tell you in advance they're doozies.  The Ultimate "loose cannon" of allergists--the Angry Allergist--chose these finalists himself, after recommendations from our committee.   Frankly, even I have trouble choosing between them.  But don't worry, you can't go wrong.  Any choice seems ok with me.  The CRAP will tally votes, and then we'll announce a winner if we have one in an upcoming Blog listing. So drop me an email and vote now!   Operators are standing by.     Later, Dude. 

 Finalists in the Second Annual Allergist Poster Contest:

     Entry 1:        Entry 2:        Entry 3: 

As a blogger, I love it when readers write in...it means somewhere out there people are actually READING this stuff...my last entry talked about the potential for a "Hidden Agenda" propagated by the major allergy societies for SLIT..."packaging" it so that the traditional allergist is the sole purveyor of treatment, by "pumping up" it's side effect potential so that other physicians won't be as tempted to use it.  A reader wrote to me after this entry,

I have been thinking about an interesting medical legal point.
Traditional allergists live in fear of lawsuits from anaphylaxis. It is a problem of their own making.If SLIT is accepted and recognized as very safe, then a physician using a much less safe method does not have a defensible position.A reasonable patient would choose a safe method of treatment which is effective. So part of the SLIT anaphylaxis campaign is to protect against reasonable lawsuits from SCIT anaphylaxis where the physician
did not choose a prudent treatment method, ie SLIT.Even if there really are a handful of adverse reaction from SLIT, the relative risk is several orders of magnitude higher for SCIT.

You're right, pal.  This is one more reason to inflate the side effects of SLIT.  So look for more emphasis on SLIT side-effects in the future.  We can't have a treatment that's TOO safe, right?  It would make injection immunotherapy (SCIT) look bad.  And we don't want that now, do we? 

Later, Dude

I'm a father of 3 teenagers; and I've learned that sometimes underneath the apparently innocent straight-forward question, "Dad, can I borrow the car?" there's a hidden agenda.  I love my teenagers dearly, and usually (if there is) a hidden agenda, it's relatively innocuous. 

But sometimes I've been glad I've asked myself if there's been a hidden agenda.  Because occasionally there was a hidden agenda.

And I was glad I asked the question. 

And it is in this spirit that I have comments and concerns about how our major allergy societies will view sublingual immunotherapy (SLIT).  Like my teenagers, I dearly love my allergy societies that I belong to.  But like my beloved teenagers, I think it's healthy to ask if there is sometimes a "Hidden Agenda" at work.  I realize that there is always a fine line between being paranoid and being prudent.  But for argument's sake, let's let the ultimate "loose cannon" of allergy--the Angry Allergist--fire off a shot or two, and "weigh in" on this topic.  

We all know that our major allergy socities have SLIT on their agendas--ostensibly to study, debate, and ultimately comment on the usefulness of SLIT to treat our allergy patient population. 

But what if there's another agenda--a Hidden Agenda that is either consciously or subconsciously on our collective minds?   

Why would the Hidden Agenda make sense?  How could it involuntarily arise?  In my opinion, the Allergy Profession  is going through its Second Great Crisis.  What was the first crisis?  The development and subsequent wide availability of effective non-sedating antihistamines and effective asthma controller medications that non-allergists could prescribe.    Non-allergists could suddenly treat asthma and allergic rhinitis cases without referral to the allergist for injection immunotherapy.  I remember being interviewed on television about one of our professional allergy societies stating they were against loratadine being OTC.  Why?  To protect "our" patient population, it seemed to me.  And it really made no sense that benadryl could be OTC but not loratadine. ..unless a Hidden Agenda is invoked, that is...

Now we have a second Great Crisis in the Allergy Profession:  The potential availability of a form of immunotherapy that is safe enough to be done by non-allergists.  Grazax is available in Europe.  SLIT will be available soon here.  And the ENT community has shown a great deal of interest in it. In fact, alot of family physicians have shown an interest in incorporating it into their practices.  But not allergists.  They still have injection immunotherapy, and it's their Exclusive Domain.  Could this have something to do with why we don't have a rush for more American-based SLIT studies?  Where are they?  If we understand the Hidden Agenda, the answer becomes obvious--as long as we have no American-based SLIT studies, insurance companies will exclusively cover injection immunotherapy as "the only game in town"...and the allergist is safe with his patient population.  A recent ACAAI poll of allergists on their biweekly newsletter gave a telling statistic--over half of all allergists surveyed were fearful that SLIT would result in a loss of income to their practices.   Could this be one reason  the American Allergist isn't rushing to prove SLIT works?  Just a thought...

Here's another puzzling phenomenon that could be explained with a Hidden Agenda--an emphasis in major American allergy position papers on anaphylaxis risk of SLIT and its potential for problems, even though many studies have shown its safety.  As long as SLIT is seen as something with potential serious complications, we have "packaged it" for being done by allergy specialists exclusively.  Generally, SLIT is so safe that non-allergists can make use of it, but if there is a Hidden Agenda, then we should be prepared for an emphasis on how scarey SLIT is, and how it is "best" left exclusively for the Allergist to do...Just a thought... 

So I wonder whether there's a potential hidden agenda that we have to watch for:  "packaging" SLIT as a technique to be used exclusively by allergists for their patients--to "capture" our patient population.  As I implied before, maybe there's a Hidden Agenda, and maybe there's not.  Also As I said before, the line between paranoia and prudence is a fine one.  But as a father of 3 teenagers, it has paid off to watch for hidden agendas.  And we allergists should do the same.

Later, Dude