Caveat Emptor on Sublingual Immunotherapy.

The synthesis of clinical trials of sublingual immunotherapy for grass pollen allergy by Di Bona et al1 in this issue indicates an unimpressive small effect, and the efficacy is even smaller in the United States compared with European populations. However, what was impressive is the 70.0% (1817 of 2597 patients) proportion experiencing adverse effects (mostly mouth itching or burning and gastrointestinal tract symptoms). As these sublingual agents become increasingly available and heavily advertised, it will be prudent for physicians to be aware of these data, in addition to their cost (approximately $90 for a 3-month supply, plus the requirement to coprescribe an epinephrine autoinjector). Sublingual immunotherapy may seem more convenient than nasal corticosteroids or subcutaneous immunotherapy and therefore tempting to prescribe, but the evidence shows minimal benefit and moderate adverse effects for patients with seasonal grass pollen allergies.