#89 Is SLIT (Sublingual Immunotherapy) Underrated? With Dr. Nikhila Schroeder

In this episode, allergist Dr. Nikhila Schroeder, founder of Allergenity Health, joins the podcast to discuss sublingual immunotherapy as a standalone treatment for food allergies.

As the second installment in our SLIT series, this conversation moves beyond introductory discussions and into a broader vision of what SLIT can offer. Dr. Schroeder shares how sublingual immunotherapy may provide meaningful protection, improved quality of life, and a lower intensity pathway for families who may not be pursuing higher-dose oral immunotherapy.

We explore:

• How SLIT works and how it differs from OIT
• Expanding SLIT beyond its traditional framing
• Which patients may benefit most from this approach
• The importance of aligning treatment with family goals

This episode is part of a larger season exploring immunotherapy options in allergy care, highlighting both the promise and the complexity of an expanding treatment landscape.

Follow Dr. Schroeder:
https://allergenuityhealth.com/
@allergeunityhealth

Dr. Whitehouse's book:
From Fear to Freedom: A Workbook for Navigating Allergy Immunotherapy
https://a.co/d/003saZ8p

Special thanks to Kyle Dine for permission to use his song The Doghouse for the podcast theme!
www.kyledine.com

Find Dr. Whitehouse:
-thefoodallergypsychologist.com
-Instagram: @thefoodallergypsychologist
-Facebook: Dr. Amanda Whitehouse, Food Allergy Anxiety Psychologist
-welcome@dramandawhitehouse.com

Transcript

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Nikhila Schroeder, MD 0:00

We've all seen that babies like to put everything in their mouth, right? So they put their fingers in their mouth, they put their feet in their mouth, they put somebody's shoe in their mouth, they put whatever they find in their mouth and they don't eat it necessarily. They kind of suck on it, and they allow that oral mucosa to come in contact with the world around them. So sublingual immunotherapy is a route that uses that very special place in the body where tolerance is generally it's natural slant. It's generally what it wants to do, and puts these proteins that the body has misclassified, has made an error about and called an allergen. It puts those things right there and says, Hey, look at them again. There's nothing scary on this.

Speaker 0:51

Welcome to the Don't Feed the Fear podcast, where we dive into the complex world of food allergy anxiety. I'm your host, Dr. Amanda Whitehouse, food allergy anxiety psychologist and food allergy mom. Whether you're dealing with allergies yourself or supporting someone who is, join us for an empathetic and informative journey toward food allergy calm and confidence.

Amanda Whitehouse, PhD 1:15

If you've been following this season, you know, that we've already explored sublingual immunotherapy or slit as one of the evolving options in food allergy management. Today's episode builds on that conversation with my guest, Dr. Nikhila Schroeder, allergist and founder of Aller Annuity Health. She's known for her patient-centered approach to immunotherapy with slit and pushing us to think more expansively about what is possible. In this episode, we explore what SLIT can offer on its own, not as a lesser option, not as a compromise, but as a treatment with its own strengths, applications, and potential. If you have ever wondered whether there is a middle path between strict avoidance and higher dose immunotherapy, or if you're looking for a more nuanced conversation about thresholds, safety and quality of life. Stay with us. Thank you so much Dr. Schroeder, for joining us here on Don't Feed The Fear

Nikhila Schroeder, MD 2:08

Inviting Me. I'm excited to be here.

Amanda Whitehouse, PhD 2:11

Would you tell us a little bit about you first? I'm curious because your degrees are MD and is it a master's in engineering?

Nikhila Schroeder, MD 2:18

Yeah, master's in engineering.

Amanda Whitehouse, PhD 2:20

So tell us a little bit about that.

Nikhila Schroeder, MD 2:21

Sure. I've always been interested in the healthcare field and pretty much since I was little, wanted to be a doctor though the first type of doctor I wanted to be was a cardiothoracic surgeon because I saw a heart transplant in high school. I was honored enough to be able to shadow that at a local hospital. It was just so amazing to me. So I always thought I'd be a surgeon, not an allergist at the beginning. I. I like to problem solve and innovate and create solutions. And math and science and physics also had always spoken to me. So for my undergrad, I went to MIT and I felt like engineering would be a good, solid foundation to help me grow in problem solving skills and creative projects, and also maybe work in biotechnology or something like that later on. But when I reached the end, I did my bachelor's and master's there with engineering and. Then still wanted to be a doctor. Even though I had job offers from engineering that were gonna pay me, I still somehow wanted to pay to go to medical school and become a doctor. So I went to medical school in Wisconsin at UW Madison and did a pediatrics residency at the University of Virginia in Charlottesville. And I have allergies myself, but that actually wasn't what drove me to become an allergist. I just saw so many babies and children with eczema and food allergy and asthma and seasonal allergies. The first time I saw a baby have anaphylaxis right in front of me, really stuck with me and really kind of lit a passion in me for wanting to help. These children. After that, I went to Allergy fellowship also at UVA and the rest is history from there.

Amanda Whitehouse, PhD 4:09

I know people would be curious, since you mentioned that you have allergies, do you mind sharing about your own. Journey with allergies.

Nikhila Schroeder, MD 4:15

Yeah, no problem. I had pretty severe environmental allergies, which crossed over into the food realm with the food pollen, cross reactivity syndrome, um, or oral allergy syndrome. We weren't a family that went to the doctor a lot, so I never got formally diagnosed. I just sort of suffered with rashes and swollen eyelids and sneezing and. Turning into infection and didn't really know what was causing it. Later on when I realized that I had bad eczema, I realized that my nasal symptoms and breathing issues were related to dust mite and ragweed, pollen and grass, pollen and cats really kind of at least allowed me to have walked the walk with several of my patients in dealing with allergic symptoms and several foods Over time, I noticed. You know, would cause my mouth to burn and my throat felt weird and swollen and kind of scary sometimes. And later on, of course, started to understand what that was about and, and which foods were causing it. And as I became an allergist, of course, understood the connections better and realized what I could do to help myself. So I actually went under treatment with someone else, but continued the therapy myself with a sublingual immunotherapy. I was a fairly quick responder and within a few months I already saw major improvements. And, and now I am in my remission period in a period of, of very long sustained unresponsiveness at the moment where I'm off of treatment and enjoying things, and we're just taking a few mild precautions to try to maintain this remission. Hopefully everyone's course is different, but that was mine, and I've walked the walk with the symptoms and a form of treatment.

Amanda Whitehouse, PhD 5:56

That's great. Well, and so for those who are listening, we already did one episode about Slit with Dr. Allison Freeman. So for those of you listening, if you missed that, you might wanna back up just to get a little more basics. But obviously every person using this might have a little bit different way of explaining it. So why don't you give your typical explanation of what Slit is and how it works?

Nikhila Schroeder, MD 6:17

Sure. So Slit is the short name for sublingual immunotherapy. And really it's more of a oral mucosal immunotherapy in my opinion. We use the sublingual space, but there's also other spaces in the mouth that can be used successfully for this treatment. And so sometimes I actually do use some of those other areas. So really it's the oral mucosa, the surface of the mouth inside that we're using, where we place small amounts of allergen in the form of proteins and allow that. Protein or hope that it's going to be captured by a certain type of immune cell in the mouth called a dendritic cell, and so that that type of immune cell has a great opportunity when you put a soluble protein or an allergen on it to reach up and grab it, sample it, kind of break it down and try to understand it. Understand the environment in which it showed up, in which in the mouth is generally a tolerance promoting one. Um, I like to explain that our mouth is an area that's designed to open and it's designed to come into contact with. Things that we're supposed to tolerate for existence, right? So things in our air that we breathe in general, we need to tolerate. Otherwise that would be a problem. Things in water, we need to generally be able to tolerate and things in food we need to generally be able to tolerate and our mouth is a place that comes in contact with all of those things. Additionally, thinking back to just how our, our. Youngest versions of ourselves, how babies start to interact with the world around them. It's a nice other visual for patients to understand this route of treatment. We've all seen that babies like to put everything in their mouth, right? So they put their fingers in their mouth, they put their feet in their mouth, they put. Somebody's shoe in their mouth, they put whatever they find in their mouth and they don't eat it necessarily. They kind of suck on it, and they allow that oral mucosa to come in contact with the world around them. People have studied what happens there, and it does in general suggest tolerance promotion. So sublingual immunotherapy is a route that uses. That very special place in the body where tolerance is generally it's natural slant. It's generally what it wants to do, and puts these proteins that the body has misclassified, has made an error about and called an allergen. It puts those things right there and says, Hey, look at them again. There's nothing scary on this. This is not a bacteria. It doesn't have any of those markers. This is not a virus. It doesn't have any of those markers. Look at it more closely, break it apart, process it, and then go travel and send your message and reeducate other immune cells like the immune cells in your lymph nodes, for example. Go educate them again and say, Hey, look at this. This is harmless. Do we really need the response? Do we need as much of a response to fight this? Because of course, it's the immune response that's actually causing the danger and the threats and the symptoms and uncomfortableness from allergy. So how I explain it to our patients who are trying to understand it compared to other options is that we're going back to basics. We're going back to. Being a baby and reeducating the immune system from its first useful route.

Amanda Whitehouse, PhD 9:52

Perfect. So then continuing on that, when someone comes into your clinic and is interested in this treatment, what do you tell 'em about who this can help with? What allergens what, what maybe of their individual medical differences or situations is this an appropriate or helpful option for?

Nikhila Schroeder, MD 10:09

Yeah, I really believe. And have seen that slit could and should, if we could find ways to make this work, societally could be really a great first line treatment for essentially any type of allergy and potentially even has an avenue to be used in allergy prevention or in non-class allergic syndromes, like F PIs and other things. So I think it's potential at the moment is. Largely untapped, and there's so much more that could be done with this, but we focus, obviously, some of that is highly experimental and we're very clear about that with our, with any patients who are asking about that, and some of the unique things that we do with slit. The main thing is for anyone who has an allergy food and environmental especially, it could be a useful treatment. We often get asked, you know, what age can you do slit? What ages is it effective? Really any age as an infant or in the first few years, that's a, a fantastic time if you do happen to be diagnosed with an allergy, to get in there and, and start a treatment because a lot, the immune system is trying to soak in knowledge and learn things. And if we can get in there before it's gone too far off the rails, we can just see dramatic changes. But even older than that, it's not like there's no hope. So I was an adult, like I said. I didn't even realize I had allergies until I was embarrassingly old. And then it was very obvious in med school, right, that I somehow had missed the boat on understanding that we have many adult patients for whom it can be effective. It might take longer, but it might not, but it might, and you might need higher doses. There's variations of it that we might have to consider, but it's not that, that the immune system can't learn at any age. And the other question sometimes we get about age is part of the treatment involves trying to hold. The, the droplet from the immunotherapy in the mouth to let it come in contact with those dendritic cells. So what about infants? They can't hold it, right? So of course infants, you can't give them the instructions to hold it, but we can find ways to make it highly effective because you can use other areas of the mouth. So there's, um, the vestibular area, which is kind of the lower outer part of the gums. So I might have a patient pull out their cheek, the baby's cheek, and just drop it down at the base there, or pull out their lip and drop it down there. Very hard to immediately swallow from the outside of your teeth. In our clinic at least, we really focus on trying to keep the volume of the liquid for the dosing quite small. And so we also try to make it thick and viscous. An example I give is take a small, tiny drop of olive oil or something like that and put it. You know, underneath your tongue, and then actively try to swallow it and see where, where you think it goes. It's not gonna go very far, at least not for a while until you have a lot of saliva pooling there. And then maybe some of it will go somewhere else, but even still. It has a lot more of the oral mucosa to still get to before it gets anywhere else. And eventually the tiny, tiny amount that might get further by then, so much of it's been captured. So I do think infants can do it successfully as long as we take certain precautions. And then there's the variations, which we can talk if you'd like to go. More detail of someone starting with multiple allergens versus one or. Really high test results, really big skin prick tests, or really high numbers, greater than a hundred to something for IgE or a history of anaphylaxis, all that kind of stuff. It plays a role, but it, none of it to me rules out the ability for slit to help, and I've seen it help patients in all of those scenarios and.

Amanda Whitehouse, PhD 14:00

That's the point in general that I wanted to have you get on the show to get across to people, because a lot of people are frustrated. We missed that early window to do OIT when it's really most effective. Or my child's IgE is too high, my child is too sensitive. I have been told that we're too sensitive for OIT or my child has eoe. They're not eligible for any treatments. Mm-hmm. So all of those things. Any of those things, what do you say to patients?

Nikhila Schroeder, MD 14:24

Sure. There are so many variations, right? And so the overarching. Point that I try to make to patients is that slit is the safest current form of immunotherapy and it has been demonstrated and proven to have efficacy with environmental allergens and with food allergens. If you have high numbers or big tests, that certainly doesn't rule out someone from being able to use an option like this. We might need to go to higher dosing in the long run to see those things move. We might not, but I do kind of tell patients we might have to push more. We have to watch and kind of see a little bit how things are going, but we might need to push more, whether it's using a real food at some point to get to higher doses, more cost effectively, or increased cost of using an extract at higher dosing and things like that. You can still try and you can still often get some movement very safely from this. Very gentle. Process on the body. Likewise, patients with eoe, patients with asthma, patients with significant eczema, there are ways to do slit with all of those types of patients. It's of course best to have those medical conditions well controlled before starting, but it's not totally necessary if you're working with someone who can really navigate the nuances. There are ways I've started patients in all of those realms. Safely on slit. We've gone through the discussion away, the pros and cons of starting now, starting later, doing a different treatment option, doing nothing. And sometimes if someone was stagnant in being able to see improvement, they're already on medications and they're not seeing improvement in their eczema or asthma. Sometimes slit is the thing that appears to. Bridge them to that improvement because what we needed to do was get the immune system to understand its mistake and maybe the medicines are most likely not doing that. They're suppressing something or they're trying to control symptoms, but they're not changing the immune system in the way that would calm it down or make it potentially build some other blocking factors or balancing factors or respond less enthusiastically to the exposures split. Can be a way to do that, that is gentle enough that you can use in those scenarios. There's no real contraindication, in my opinion, to slit, especially if someone is well versed in how to navigate it, because especially if you are using a liquid like we do, you can dilute a liquid as much as is needed to find. The spot that the immune system can handle.

Amanda Whitehouse, PhD 17:02

Mm-hmm.

Nikhila Schroeder, MD 17:02

And so if someone is getting a side effect from the treatment, we can just lower the dose and then wait and let the immune system engage at whatever that low level is until it's ready to move on and then build up again. Sometimes if we have to back down. It's not like we haven't then been able to build up. There's always, there's occasional patients who, once they have some symptoms, the person's not interested in further engaging or it's just not a good fit for adherence. And I'm sure there's somebody who I'll find that maybe doesn't have enough dendritic cells in their mouth or something where it just doesn't seem to move the needle for them. But thus far, with some creativity. Changing the dosing spot or playing with doses or switching the form from food extract to real food or vice versa. We generally can push things forward for pretty much anyone at any age with any type of allergy. If you give it some time and you're adherent to your dosing. Once I learned some of that background, some of the science. There were plenty of studies that already suggested how useful this could be, like decades ago and tried it in patients and just saw how safe and effective it could be. It just didn't make sense really to me to not use it and to use other more aggressive forms first when we have something this gentle and, and this effective that can be tried. Another benefit to it is its logistical aspects are pretty minimal. Droplets in your mouth. No rest periods don't have to come to the clinic very often for shots. There's a whole host of benefits that I could go through that also make it very easy for families, which is also something I wanted for my patients because the world is hard enough. We all have so many things on our plate, and, um. I see often in a allergy family's eyes, that feeling of being overwhelmed. Um, any of us feels that way, I think, in the regular world right now. But add on managing a food allergy or worrying about your child's health or dangers of food, which is all around us all the time, and then trying to pick a treatment and. Potentially learning that a treatment involves a lot of logistics. There's families that one parent has quit their job to manage a form of treatment, or you're waking up early, or you're skipping sports, or you're eating a bunch of these allergenic foods and carb loading, and now nutrition is changed, or you're gaining weight, or you have tummy aches. There's a lot of things with some of these other treatments, whereas with slit. There's really not a whole lot of any of that and it can be very helpful. And so starting there, seeing what it does for someone, you know, I love doing that and, and many times you can go pretty far and meet most goals that way. And occasionally, if you can't, what's great is it's already laid a great foundation, most likely for a patient. So if they want to transition to something more aggressive or we have patients who have tried something more aggressive and have had trouble, and so then they switch to slit. Either we complete their process with slit alone to the degree that we meet their goals, or we might do slit for some time and then they bridge back into something like oral immunotherapy or, or something more aggressive with ingestion and it goes differently because the body had some time to just sort of adjust a little bit. Almost always, if you truly have allergies and are looking for help, there's a version of slit that could be tried for you.

Amanda Whitehouse, PhD 20:26

Okay. And I just wanna clarify about eoe. It sounds like you can work with that.

Nikhila Schroeder, MD 20:31

Yeah, absolutely. So much in the allergy field that's evolving and science that still needs to be discovered and uncovered about allergy alone and let alone EOE and eoe. Shirley has been around for a long time, but hasn't really been understood till the past, you know, couple decades where we've started to hear more about it and started to understand it more. It's kind of very similar to asthma and atopic dermatitis or eczema in the sense that it's this spectrum, right? Some people can have very mild eoe, some people can have very severe EOE and strictures and real problems eating, but everything in between and it's inflammatory. Allergens can trigger it. So IE kind of is joining the club with being, being multifactorial and with slit and being something you can easily, fairly easily modulate and being so gentle. Um, so if someone wants to work on their, their allergy, but they also have eoe, sometimes it's the same food and you know, they, maybe they tried OIT and they saw that their peanut allergy. When they did peanut, OIT also triggered their eoe, right? Or milk. Milk is one of the most common ones, but sometimes it's not an allergen. Sometimes it's something else. So they're allergic to peanut, but milk is triggering their eoe. Something like that, right? We might go start lower. We might go much more gradually. And if we have any concerns about a flare, we can always have that assessed and then see what we think. There's plenty of times kids get GI symptoms all the time, so we're navigating that plenty. But for non immunotherapy reasons, kids get GI symptoms all the time, constipation, tummy aches, et cetera. And so the easy thing to blame is immunotherapy, right? When a child who's on slit has some stomach issue. I often get a call from the family saying, Hey, we haven't changed a dose recently or anything, but this has been happening, and our other doctor, and he's like, oh, it must be your immunotherapy must be slit. You should stop that. Right? So they come and ask me what should we do? Another nice part about slit is sure we can do a trial off of it because it's also, we're not walking such a tight line that if we stop dosing for a little bit, then we have to do a whole big intensive thing to keep you safe when we restart. Usually don't have to. There's not a whole lot of risk to restarting. And so even though it's probably not the slit that's causing the GI symptoms, sure, let's stop for a couple weeks and let's see. And I have a nice little pattern of what I advise my patients to go through to look for before you stop the slit. When you stop the slit, and then we have them reintroduce the slit and what to look for there. And all that data we put together to try to figure out if it was the slit or not, and. It generally is not the slit, and that helps the family also feel comfortable about that. There's a few case reports I think, of EOE that may have been triggered by someone's slit based on timing and biopsies and things like that. I tell patients, sure, I think it's possible, I suppose, but certainly if we keep to a more gradual regimen, it should be less likely. If we control the volumes in your mouth that you're holding, it should be less likely. If we wanna hold and spit it out, instead we can do that to be more comfortable that even less is getting to the esophagus. Um, there's, there's lots of ways to kind of mitigate. Um, the risks with doing slit with eoe and in the end we can always down dose or always stop if we really need to.

Amanda Whitehouse, PhD 24:07

And you mentioned something that I think is also confusing for people who are looking into this. Some people when they're practicing slit, have the patients swallow the liquid and some people have them spit it out.

Nikhila Schroeder, MD 24:17

From my understanding, most practices do the swallowing version, but like I said, occasionally for a particular patient, if they're. Especially if they're worried about it, then, then we would have them spit. But most of the time patients are, are able to to hold and then just swallow the saliva that accumulates without an issue.

Amanda Whitehouse, PhD 24:36

Okay. All right. So please talk to us about goals and how far we can get.

Nikhila Schroeder, MD 24:41

Yeah. Every family has different goals. Some families only have one allergen, some families. Might have 15 food sensitizations that appear relevance and environmental allergy and asthma and eczema and maybe eoe. You know, they have, they've done the holy atopic march. Um, and so goals can vary widely, but I go back to what I heard most from families, and I still hear this most from families. Before I started doing slit was when I was a pediatrician and I would see all these allergic patients. And I would try to help them with the tools we had at that time. What I most frequently heard was, of course a cure would be great. Everybody wants to cure any health element they have, of course, right? But they're like knowing a cure is not available at the moment. We just wish we could do something that would potentially move the needle and build a better buffer of protection.

Amanda Whitehouse, PhD 25:43

As an allergy parent, it's like I can handle the allergy, just not the anaphylaxis. Is that kind of what you're getting at like in, in terms of moving the needle toward, we might not have this. Yeah. Really life threatening reaction. That's the buffer we want.

Nikhila Schroeder, MD 25:55

Right. Anaphylaxis is scary. It has the medical component, it has the psychologic component, both for the child and the parents. It's a big deal and is always on family's minds, right? But then there's also the quality of life aspects of going to friends' houses, or what happens at school, right? Feeling included and not feeling isolated from certain events, which is also a big deal. So the. Risks and the isolation are really what came out to me most when I would listen to families that they were hoping to improve in those areas, right? And I certainly didn't want a treatment that added more. Risk or isolation to their lives, but they wanna do something. And that really solidified some of the benefits of SLIT for, for me, for patients in that here's a thing that was fairly easy to incorporate in their lifestyle that didn't add a whole lot of risk and that could move that needle and meet that, those major goals of reducing the risk of anaphylaxis. And allowing them to have a better quality of life and be less isolated. Get out there, do the things they have fun with, and feel better and be safer. I never like to use absolutes in anything with the immune system because there's always gonna be somebody here or an immune system that's working really differently. But in general, that goal can be met for so many families with slit, and a lot of people think that that's it, though, that it doesn't also have a capability. Of building further protection beyond kind of axonal exposures or cross contact, and that's something important I'd like to make sure to mention is that's not true. Slit absolutely can and has brought some patients to being able to eat large amounts of their food allergen. These things can commonly be achieved as well from slit and aren't talked about as much. Usually slit is seen as. The thing that you can do to meet the low end of the goals.

Amanda Whitehouse, PhD 27:59

Right?

Nikhila Schroeder, MD 27:59

But not something that you could do to meet higher goals, but it can, I despise the term free eating and food freedom with allergy, which I can go into if you'd like, but I, I think that, uh, gives a bit of a false sense of security with former food allergens. But eating foods in, in large amounts fairly. Unhindered. It is possible for some people with some of their allergens, mu slit. The interesting part is that I have had many patients who have passed that full food challenge who then are like, you know what? I don't want eat that food ever again, though. I'm glad to know that I have protection, but I have no plans to continue eating eggs every day. Mom or dad?

Amanda Whitehouse, PhD 28:45

Usually it's the kids. We think, oh yeah, you can eat this. That's how we were, my son could free eat peanuts. Like I have no interest. And then when we needed to do more food allergens, he wanted to do slit because he is like, I don't care if I can eat it. I just don't wanna get sick from it. So it's absolutely, it's often the kids, we think we're giving them this huge freedom. Don't. Care about it sometimes. Yeah. To dose slit every day is so much easier and minimal. Versus like maintaining an OIT dose where you're actually eating. We do food based, so you have to mix it, which is obviously a step that needs to be done periodically, but it's really so easy to maintain that. I don't think for a lot of people that's a huge barrier.

Nikhila Schroeder, MD 29:20

No. If I was, um, emperor, Empress of the world right, and could just make certain things happen, I would. Find a way to make slit very affordable. Extract slit, if I could, because that's even easier than real food slit. But real food slit certainly is. Is that because

Amanda Whitehouse, PhD 29:38

it lasts longer?

Nikhila Schroeder, MD 29:40

It lasts. It's more stable, it's more soluble, probably, you know, people need to study this a little bit more, this purified protein. Mm-hmm. So that potentially is even more soluble than, than using a real food that has fats and carbohydrates and things mixed in. We need more data on that you just mentioned. So for real food slid our patient's doing that, they have to mix it themselves. Right. So that is a little bit of a step. It's not a super hard one like you mentioned. So it is possible, but for one, two, or three allergens, many families. Seem to be able to do that quite well. When you get to the families who, maybe it's not the young child, maybe it's the teenager already who's gone through that atopic march and their immune system went off the rails early and they've racked up so many relevant real sensitizations that put them at risk. How do you do real food slit or OIT with like 10 foods?

Amanda Whitehouse, PhD 30:28

Mm-hmm.

Nikhila Schroeder, MD 30:28

15 food, you know? Um, that can be really challenging. And so extract. So much easier for those types of patients, right? Because that's worked for me. That's worked for the clinic. Where we have to compound the vials, but it's no work for the family in terms of mixing. They just have to dose. Right? So the biggest problem with that is cost and what pharmaceutical companies are charging for that, and the cost variations between different clinics for that and what clinics have to pay. They're different for clinics too, which I know is a topic of confusion. But you know, the cost really, I think is what hinders using slit. For kind of the long, long, long term option for some families. Mm-hmm. There are still some families that choose it. I absolutely have families who pass the food challenge and the child or, or even if they're just not even interested in a food challenge, they've opened the doors, they wanted to, they met their goals, and now they want to maintain with slit. And we talk about real food slit and the kids' like, no way. Or the parent's like, I don't have time for that. Right. And so then they have to work it into their budget. And some families can. And some families, that's gonna be harder or you know. Completely limiting. Right? And so that's the unfortunate part with extra slit. But if that barrier was able to be removed, then I truly think that using slit for many families as sort of the background of their allergy management, mm-hmm. Just wake up. Do some drops go on with your day right? And you do it maybe for your whole life. Maybe you know, like we treat diabetes and other medical conditions that are lifelong allergy is lifelong doing slit daily kind of forever. Um, I think would be fantastic if those other factors could be controlled and I think a lot of families potentially would choose something like that over than having to try to eat the foods. Which we know doesn't always last very long for some children.

Amanda Whitehouse, PhD 32:29

There's one more thing that I wanna touch on. As a mental health professional, I feel like slit is such a good option for kids who are anxious or have traumatic experiences, either with their food allergies, with treatments perhaps, and I was wondering if you could touch on that and what you've seen.

Nikhila Schroeder, MD 32:43

Yes, that's another huge benefit to sublingual immunotherapy. We have some families who only do extract. That's been their choice. We have some families who only do real food slit or pair that with an environmental slit with extract, but for the foods, they're only doing the real foods from the beginning. And we have other families who do extract slit for a while and maybe do real food slit later on. To maintain, to control costs in the long, long term, potentially. Right, or because of that psychologic element in that at the beginning, they were nowhere near ready to interact with the real food, to have it in their home, to have to mix it or clean things. That had involved the real food to taste and smell the food. I have ways to try to mask it a little bit and things like that, but taste often can come through and psychologically, for some families, for many families, they're just not ready for that at the beginning. And extract slit then provides a fantastic route because it doesn't have any of the flavors. It looks and feels like a medicine, but it's sort of. This beautiful bridge between medicine and the real food in that yes, it's a pharmaceutical product and that comes with the cost and some of the downsides of that, but also it's just food protein. It's not really a significantly altered or artificial product. It's food protein that just happened to be purified and processed, right? So to the patient it, it feels like a medicine droplet. And that's really not scary. So it's a really nice, easy place to start with for many, many families. I've had one patient who psychologically just was not even ready to start extract slid.

Amanda Whitehouse, PhD 34:28

Mm-hmm.

Nikhila Schroeder, MD 34:29

And that was a teenager who was, I think 16 years old at the time. Who had so much anxiety and fear that had built up over their lifetime, very understandably, with what they had gone through. OIT was definitely not an option. So the family was hoping that slit would be, and we had a couple really nice consultations and he could tell that the teen, he, he wanted to do it, but he was mentally, he was so. He was so scared. And I tried some of my little tricks that I do to slowly expose and just let him hold the bottle and watch me mix it and things like that. And he almost tried, but he was like, you know what? I'm just not ready, and that's okay. And that's what we told him. He said, Hey, that's okay. And when you are ready, if you're ready someday, it's still an option. It's still here. But it just really impressed upon me how real that anxiety is. And. How much that needs to be overcome to sometimes engage with the treatment. And slit is just fantastic overall for that because. Especially with the extract, most kids are like, what? Oh, okay, sure, that's fine. That's not scary. It's more the parents sometimes at the beginning that I've had to really answer questions thoroughly and kind of take the time and try to reassure them.

Amanda Whitehouse, PhD 35:45

And I think understanding the difference like we're trying to do and spread the word, and I know you're trying to do this too, will help people to understand that because there really is such low risk, there's such a high safety profile for this,

Nikhila Schroeder, MD 35:55

you know, less than 5%. Um. I mean, that's probably what it's in our clinic. I think that's what it's been in some studies, some more aggressive protocol studies. Maybe it's been higher than that. But again, the side effect profile is not anaphylaxis.

Amanda Whitehouse, PhD 36:09

Right.

Nikhila Schroeder, MD 36:09

It's it's oral itching. And then there's

Amanda Whitehouse, PhD 36:13

it's

Nikhila Schroeder, MD 36:13

discomfort

Amanda Whitehouse, PhD 36:13

which come, which is worrisome. But

Nikhila Schroeder, MD 36:15

yeah, absolutely. It's especially because oral itching sometimes is what leads, you know, as a first sign of anaphylaxis. So of course we wanna pay attention to it and try to figure it out, but that's just not where it tends to lead with slit. One of the studies that used a pretty aggressive protocol in Canada did have a small number of people where epi, use epi was used after a slit dose. They don't really go into detail. So they went with a faster, more aggressive protocol, and then they reported that a few patients did choose to use EPI for some of their doses. And we don't really know the details, but in general, that's super rare to be reported with Slit. It's certainly something I have never seen in my practice in the past decade. I have not had anyone have anaphylaxis to their slit dose. The clinic I worked at where I initially learned their slit protocols, we do things differently at our clinic, but you know, they have their version of slit in LA Cross, Wisconsin. They had been doing it for 40, 50 years. They had not seen anaphylaxis to their slit doses, and the majority of the studies do not have any anaphylaxis to any of the doses. So the side effect profile is really small and mainly limited to something mild like that. The other thing I do caution patients about is a little bit of an eczema flare if there's someone with significant eczema, and again, slowing it down and going lower usually just takes care of that. So it's fairly easy to navigate and keep it controlled. For families.

Amanda Whitehouse, PhD 37:38

Good. Well, thank you so much for sharing all this. I could ask you questions all day. You've got a sore throat. I don't wanna make you talk for hours. I'm sorry.

Nikhila Schroeder, MD 37:44

I'm so sorry I'm sick today.

Amanda Whitehouse, PhD 37:45

No, you sound, I mean, you sound fine, but I just know you're not feeling well. But would you please just tell everybody listening where is the best place to find you if they are interested in working with you?

Nikhila Schroeder, MD 37:54

If someone has questions, feel free to reach out to our clinic because James, who's my husband and the practice executive, he's very knowledgeable about this and can help, or I answer the phone sometimes, so I might. Be able to help. We know a lot of the more experienced slit providers and allergists across the country, and certainly in the past few years, slit has finally started to get some attention, which I'm so excited about that more and more people are understanding how amazing this option is and are trying to incorporate it in their practice. So we do have kind of knowledge of. Many people who are providing it are happy to connect someone with a clinic that's closer to them. If they can't travel, you can reach us in lots of ways. Probably the easiest is to start with our website. So our clinic is Allergen Health. Um, it's kind of hard to spell. Is that something that you'll put with this? I'll put a link

Amanda Whitehouse, PhD 38:46

in the notes for

Nikhila Schroeder, MD 38:46

sure. So look for that. It's

Amanda Whitehouse, PhD 38:49

like annuity, but aller annuity, right?

Nikhila Schroeder, MD 38:51

Yeah, we, the name briefly came from. We knew we were different. We're really genuine in what we do, and we are creative. So we put allergy and genuine and ingenuity for creativity, and we put that all together and that's how we came up with our name. So it's a little bit of a mouthful, but I think people get it once they say it a couple times. Our website, aller annuity health.com, and then we are on Instagram. And Facebook,

Amanda Whitehouse, PhD 39:19

and I'll put it in in all of those, in the links that I put in the notes for the show episode too. And tell people where you're located. I don't think we said that yet.

Nikhila Schroeder, MD 39:26

Oh, sure. Yes. We are located essentially in Charlotte, North Carolina. Our specific city is called Huntersville, but it's basically the north side of Charlotte. We are happy to see anyone who feels like our style of care and sublingual immunotherapy is helpful. We have patients that are local. And we have patients from all over the world actually. So it's been a very humbling and very honored that PE people have trusted us and seen results from us, that they've come from all over. So we certainly are happy to help people find someone more local, but if they wanna see us, we have processes for that, that try to streamline it for them. So always happy to help or point you in the right direction.

Amanda Whitehouse, PhD 40:05

Great. Well, I'll put all the information there so people can find you, and I appreciate you sharing so much.

Nikhila Schroeder, MD 40:10

Yeah, absolutely. So thank you so much for having me on today. Appreciate it.

Amanda Whitehouse, PhD 40:14

Yeah, it was wonderful to meet you. Thanks for doing it.

Nikhila Schroeder, MD 40:17

Thank you.

Amanda Whitehouse, PhD 40:18

If this conversation opened up new ways of thinking about slit and immunotherapy options, here are your three steps. First, you can find Dr. Nikhila Schroeder to learn more about her work and perspective at Allergenicity Health Online. The link is in the show notes. Her practice is on Instagram at Allergen Health, A-L-L-E-R-G-E-N-U-I-T-Y Health. Second, if you're interested in exploring immunotherapy with other providers, visit fast oit.org to look for a provider near you and to learn more about your options. And third, if you are struggling to navigate the emotional, logistical, practical, or mental health side of choosing and navigating an immunotherapy path, i've written a workbook just for you that walks you through the social and psychological aspects. It's called from Fear to freedom. The link is in the show notes. You can find it anywhere you purchase your books, but I would encourage you to consider using bookshop.org to support local bookstores. Remember that choosing a treatment is not just about the data or the medical aspects. It's about alignment with you and your family's values, capacity, and goals. Thank you for continuing to explore this expanding landscape with me. Thank you, Dr. Schroeder for being here. And thank you to all of you in the audience for listening, for liking and subscribing, for leaving me ratings and reviews, and helping the show continue to grow bigger than I ever imagined it would be. I'll be back next week.

Speaker 4 41:49

the content of this podcast is for informational and educational purposes only, and is not a substitute for professional medical or mental health advice, diagnosis, or treatment. If you have any questions about your own medical experience or mental health needs, please consult a professional. I'm Dr. Amanda Whitehouse. Thanks for joining me. And until we chat again, remember don't feed the fear.