Intralymphatic immunotherapy and the future of allergy care [PODCAST]

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Join Kara Wada, an adult and pediatric allergy and immunology physician. We’ll delve into the world of allergy treatments, exploring the challenges faced by millions dealing with seasonal and year-round allergies. From traditional methods like medications and avoidance to revolutionary advancements like intralymphatic immunotherapy (ILIT), we’ll uncover the potential for long-lasting relief and improved quality of life. Discover how ILIT targets the immune system more efficiently, its benefits compared to traditional treatments, and the future it holds for allergy care.

Kara Wada is a board-certified academic adult and pediatric allergy, immunology, and lifestyle medicine physician, Sjogren’s patient, certified life coach, TEDx speaker, and Dr. Midwest 2023. She can be reached at Dr. Kara Wada and on Instagram, YouTube, Facebook, and LinkedIn. She is a national expert, sought-after speaker, advisor, and host of the Becoming Immune Confident Podcast. She is CEO and founder, The Crunchy Allergist and the Demystifying Inflammation Summit, and serves as the director of clinical content for Aila Health.

She discusses the KevinMD article, “Intralymphatic immunotherapy: a breakthrough approach for allergies.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at kevinmd.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Kara Wada. She’s an adult and pediatric allergy and immunology and lifestyle medicine physician. Today’s KevinMD article, which she co-wrote, is titled “Intralymphatic immunotherapy: a breakthrough approach for allergies.” Kara, welcome back to the show.

Kara Wada: Thanks so much for having me today, Kevin.

Kevin Pho: So Kara’s been on multiple times. Go to kevinmd.com/podcast to hear her story in prior episodes, but today let’s jump right into the KevinMD article you co-wrote, “Intralymphatic immunotherapy: a breakthrough approach for allergies.” So tell us what this article is about.

Kara Wada: Yeah, so as we are about to come into allergy season, especially here in the United States, we are seeing worsening symptoms. We’re seeing more patients coming in. And when we think about our treatment options, we’ve had the same treatment options available for patients for this for decades, right? We have avoiding those things we’re allergic to, we have medications, and then we have immunotherapy, which are ways that we are able to change that immune response from fighting an allergen to ignoring it. The problem we’ve run into as allergists, and certainly as patients too, is that immunotherapy has not been particularly convenient or necessarily pleasant for patients either.

So the typical immunotherapy that we’re talking about, and that most people are familiar with, is allergy shots. Allergy shots have been a mainstay of treatment of allergies for well over 100 years, and they work well. We see improvement in somewhere around three-quarters of patients, and it really can decrease the symptom burden and also decrease the amount of medications folks are needing.

And yet, getting that done is a big lift for patients. It requires typically coming to the office, usually on a weekly basis, for some period of time, when the patient will start at a low dose and work their way through what we call buildup, up to a target dose of their allergens, a mix of allergens that they are specifically allergic to. And then we move over to maintenance phase, where ideally patients are coming in once a month. But that goes on for somewhere on the order of 3 to 5 years before we can see lasting improvement.

Meaning, they’re seeing improvement in their symptoms typically by the time they reach that target dose or that maintenance dose. But in order to see ongoing symptom improvement after they’ve completed immunotherapy, it really takes a long time to have that lasting effect. And so intralymphatic immunotherapy really kind of throws this long-term, multiple-visit paradigm on its head, because it really harnesses a lot of the science we have learned from vaccines, and it shortens that treatment window down to three visits over 8 weeks.

Kevin Pho: Wow. So before we talk more about intralymphatic immunotherapy, just give us a sense of the typical cases where you would consider immunotherapy in general for patients. What are some common scenarios?

Kara Wada: Yeah, so anyone who is dealing with itchy, watery eyes, runny noses, or recurrent sinus infections, those who maybe have allergic asthma, and in some cases, significant eczema that appears to be related to their allergy test results. All of those are situations where I would at least offer that as a possibility for patients.

I think one of the great things, as I’m working individually with my patients, is we talk about this three-pillar approach of allergen avoidance, medications, and immunotherapy. It’s really great because we get to personalize that approach to the patient. What is their lifestyle? What are their views on health and wellness and using medications? What are the side effects they’re dealing with? And so some patients may pull the trigger, so to speak, on immunotherapy much sooner if they are having lots of side effects to medications. Or sometimes it may have to be really bad, needing systemic steroids or visits to the emergency room, those sorts of situations where they may then be thinking about incorporating immunotherapy into their treatment regimen.

Kevin Pho: All right. So tell us about this approach, intralymphatic immunotherapy. What exactly does that entail?

Kara Wada: Yeah, so this technique really was brought to my attention many years ago. I was in this transition from resident to allergy fellow, and the research was coming out of Switzerland. So Dr. Kündig was essentially using an ultrasound, a portable ultrasound machine. He was injecting very small amounts of relevant allergens to the patient, or to the mouse in the case of the research models. And he was finding that doing a series of these three injections directly into the lymph nodes, spaced about 4 weeks apart, was seeing a similar response to what we were seeing in allergy shots and in sublingual, or under-the-tongue, allergy immunotherapy treatments. And what was amazing was, over time, that response was durable. So they were seeing ongoing symptom response now 3 and 5 years out from treatment.

And so the body of research has been slowly growing, kind of ongoing for the last almost 20 years. But there are some issues with kind of how allergy shots are billed, the payment, and those sorts of things that unfortunately have kind of stymied some of the larger trials to look at this on a larger scale.

Kevin Pho: Now, for the cases that would apply to intralymphatic immunotherapy, would they be the same that you would consider for traditional immunotherapy before?

Kara Wada: Absolutely. And I think it also opens up some doors for folks who maybe did not tolerate traditional allergy shots or sublingual immunotherapy as well. And the reason is, in our lymph nodes, we do not have mast cells. Mast cells are what we term allergy cells, or white blood cells, but they are the cells that are responsible for anaphylaxis. And so when we’ve looked at these studies, both in animal models and then certainly now in many humans as well, the risk of a systemic or an anaphylactic reaction with this treatment approach is much lower than that of allergy shots.

So that is, I think, another avenue. I’m excited to have these conversations with patients that maybe have had anaphylactic reactions to allergy shots in the past, and this was kind of written off: Now they’re too sensitive for this treatment. And this may open the door again for them.

Kevin Pho: Now, from the patient standpoint, just walk us through exactly what an intralymphatic injection would entail, and perhaps, for those who aren’t familiar, contrast that procedure with a traditional allergy shot.

Kara Wada: Yeah, so a typical allergy shot is using a very small needle and injecting a small amount, up to typically about half a cc, of allergen in the subcutaneous space. It’s a subcutaneous injection, usually in the back of the arm. And often with those injections, patients will have a localized reaction. They’ll have some itching, a little bit of swelling. Occasionally that swelling can be a little more significant; we call those large local reactions. And then we say about one in 200 patients will have a systemic, or more of an anaphylactic-type, reaction. That’s why allergy shots are always given in a medical office that’s trained to respond to anaphylaxis.

In contrast, with intralymphatic immunotherapy, we use a little ultrasound probe like our cardiology colleagues would use for a bedside echo, or maybe our radiology or our vascular docs would use, or ICU docs would use to place a line. And we do this procedure in the groin area, in part because those lymph nodes are really close to the surface of the skin. And there are a number of them located away from those femoral vessels. So we’re able to locate those femoral vessels, move away from those, and then find these little pea- or olive-like structures just under the skin.

And we use a small needle to inject about 0.1 cc of that allergen, so a smaller amount, directly into the lymph node. We can visualize that under ultrasound. It’s rated by patients who have undergone it as low. I practiced on a colleague as part of my training process. Actually, Dr. Owens, one of my co-authors, allowed me to practice, and she actually was surprised when I was done injecting saline into one of her lymph nodes. So it’s less pain, and it’s very quick and easy.

Kevin Pho: Now, are there any downsides to the intralymphatic approach?

Kara Wada: Yeah. So unfortunately, like many newer and emerging therapies, this treatment is not going to be covered by insurance and probably won’t be for some time. The companies that manufacture the allergens that we use for allergy shots and sublingual immunotherapy, those are approved for traditional allergy shots but then are used off-label for sublingual and now intralymphatic immunotherapy. Those companies don’t have much incentive to go back and ask for this expanded approval. And as we’ve kind of seen overall with health economics, insurance companies are pretty happy to not offer additional coverage without some significant push to do so. So this will likely stay in this area that’s similar to LASIK eye procedures and kind of other things that are health-related that are not covered by typical insurance.

Kevin Pho: So currently, how often do you perform these procedures, given all the constraints that you just mentioned?

Kara Wada: Yeah, so this is a program that is going to be offered where I practice, at Ohio State, later this month, and it’s currently being offered by Dr. Patterson, one of my co-authors, up in Findlay, Ohio. It is a growing area. We have several other colleagues across the United States who are offering it to their patients. But I foresee that there is a lot of potential and growth.

And recently, at our national allergy, asthma, and immunology meeting, I had several colleagues coming up saying, “Hey, when are we going to study this for food allergy? When are we going to study this for bee allergy?” I think there’s a lot of excitement over the potential. And so I’m excited to kind of be on the ground level of this and watch it as it grows, and to have another option available for patients to provide some relief to symptoms that are really bothersome and really impacting your quality of life every spring, every fall, and for some people every day.

Kevin Pho: Can you speculate as to why insurance companies are so hesitant to cover this? Because it sounds like you have three injections over a span of a couple of months versus years of allergy shots. What’s the reason why they won’t cover that?

Kara Wada: So currently, they don’t, in part because it is not considered FDA-approved. That’s kind of the line that we have been given. One of my pie-in-the-sky and audacious goals is, within our health system, to be able to prove to them the economic advantage to covering this treatment option for our university health plan members, because if you do the calculations, it will save them a lot.

And so I think once we have our own cohort of patients, being able to bring that data to them and hopefully plead our case, I’m excited at the opportunity to do that. It’s just going to take some time. And then my hope is, if we’re able to show them that benefit, then that might be able to be used as a test study or a case study for other insurance coverage and plans as well.

Kevin Pho: We’re talking to Kara Wada. She’s an adult and pediatric allergy and immunology physician. Today’s KevinMD article is “Intralymphatic immunotherapy: a breakthrough approach for allergies.” Kara, let’s end, as always, with some of your take-home messages to the KevinMD audience.

Kara Wada: I think if you are going through this allergy season having significant symptoms, know that meeting with an allergy immunology physician really can help tailor your treatment options and personalize them. You don’t have to go through life living in a fog. There are new and innovative treatments that are on the way, and we look forward to helping you have symptom improvement and improve your quality of life.

Kevin Pho: Kara, as always, thank you so much for updating us and sharing your insight and perspective.

Kara Wada: Thanks so much, Kevin. Take care.

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