Allergy Drops Consent

The purpose of sublingual immunotherapy (allergy drops) is to decrease your sensitivity to allergy-causing substances in an effort to reduce the frequency and severity of your symptoms. Sublingual immunotherapy is not a substitute for allergy medications or avoidance of known allergens, but rather a supplement to those treatment measures. In order to qualify for sublingual immunotherapy, there must be documented allergy to substances in the environment that cannot be avoided. Documentation of allergy will be in the form of a positive skin test. 

Improvement in your symptoms will not be immediate and may not be complete. Each individual patient’s response will vary, but most patients improve within 6 to 8 months of treatment. Maximum benefit may not be achieved until after 1 year of therapy has been completed. Your dosing regimen will be outlined by your Cornerstone Ear, Nose & Throat physician at the start of your treatment.  

When beginning allergy immunotherapy, there are certain risks of reactions that the patient assumes, such as local reactions and/or generalized allergic reactions (anaphylaxis). Local reactions during sublingual immunotherapy are common and are usually limited to itching and swelling in the lips and mouth. Typically these reactions occur more  

frequently at the beginning of treatment and will subside as it progresses. These reactions can occur minutes to hours after the dose is taken and can usually be successfully treated with oral antihistamines. Generalized allergic reactions  (anaphylaxis) occur very rarely with sublingual immunotherapy, but can potentially be life-threatening, and may require immediate medical attention. The possible occurrence of these types of reactions should be noted by the patient before agreeing to proceed with sublingual immunotherapy. The symptoms that the patient experiences as a result of such a  reaction can include, but are not limited to: hives, shortness of breath, a sudden and potentially dangerous drop in blood pressure, and a rapid or weak pulse rate. These symptoms may require immediate treatment and may require additional treatment in a hospital setting. At the present time, there have been no documented reports of fatalities related to sublingual immunotherapy, but the potential needs to be taken seriously. 

Currently, no U.S. Food and Drug Administration (FDA)-licensed extracts or American Medical Association Current  Procedural Terminology (CPT) codes are available for sublingual immunotherapy in the United States. In addition, this treatment is considered to be “investigational” and “off-label” in the United States for the products being used, and,  although sublingual immunotherapy is considered much safer than subcutaneous allergy immunotherapy (allergy injections), the cumulative doses required for efficacy are higher than when employing injection therapy. As a result, it is unlikely that any U.S. health insurance policy will cover the expenses related to sublingual immunotherapy.  

I have read the information above in this consent form and understand it. I hereby authorize the physicians and staff of CornerStone Ear, Nose & Throat to administer sublingual immunotherapy. I understand the risks, expected benefits,  alternative care options, and potential complications associated with immunotherapy. I wish to proceed with my allergy treatment. I agree to inform the office if I am diagnosed with any new medical conditions, if I become pregnant, or if there are any changes in medications that I am taking. I also agree to be compliant with the sublingual immunotherapy treatment plan outlined by my physician and understand that allergy immunotherapy is typically a 3-to-5-year treatment process.