Interested in Allergy Shots or Drops for Environmental Allergies?

Interested in Allergy Shots or Drops for Environmental Allergies? 


Explore Which Option Is Best For You


How Do They Work?


  • Both allergy shots and sublingual drops are forms of allergen  immunotherapy (IT).  IT is the only treatment option available that decreases your immune system’s response to your allergens. 


  • The allergen is shown to your body in miniscule amounts and then gradually increased over time. Through this process, your body learns to “tolerate” the allergen rather than view it as a threat. As this occurs, symptoms such as sneeze, runny nose, congestion, watery itchy eyes, and cough diminish. 


Why Do Them?


  • The goal of allergy injections and drops is to significantly reduce allergy symptoms and medication use.


  • Some patients start IT because medications do not work well enough. Other patients start because they are looking for a more long-term option or wish to treat the “root of the problem.” Medications help reduce symptoms while you are on them, but they do not prevent future symptoms as shots or drops do.  


What Are The Options?


  • Allergy Injections: 

Allergy injections are started weekly, then transitioned to every 2 weeks for 1o injections, then every 3 weeks for 10 injections and then every 4 weeks (maintenance). You will either be 1, 2 or 3 vials (shots) depending on your number and combination of allergens. There are 2 build-up options: Traditional and Cluster.


Traditional Build Up: 

  • The goal dose is reached in about 1 year. 
    • TIP: If you come 2x weekly, you will build-up in half the time and if you come 3x weekly, you will build-up in a third of the time. 
  • Each time you come, you receive 1 dose.
  • There is a 30 minute observation period after injections to monitor for an allergic reaction. 
  • Standard injection hours apply (Shot calendars). 


Cluster (Accelerated Build-Up):

  • The goal dose is reached in about 9 weeks, because you get multiple injection doses in one day
  • For the first 8 injections, you will receive 2-3 doses.Cluster & Venom Immunotherapy Build-up 
  • The 30 minute wait applies after each injection
    • For 3 dose days, plan to be in the office at least 90 minutes. 
    • For 2 dose days, plan to be in the office for at least 60 minutes. 
  • During the initial build-up phase (where 2 or 3 doses are administered), the “cluster” injection schedule hours apply. Once the goal dose is reached, standard injection hours apply.


  • Sublingual Drops 
  • Drops are administered under the tongue at home and are taken daily.
  • The extracts are FDA approved, but sublingual administration of the extracts is not FDA approved. Thus, sublingual therapy is not covered by insurance. 
  • Efficacy not high as with injections. 
  • Allergens can be combined, but not as many as with injections. For patients with multiple allergies, discuss with your provider which option may be best for you. 


How Long Do You Continue Therapy?


  • Injections or sublingual drops are typically recommended for 3 – 5 years. The extended duration is to help create lasting changes to the immune system, so that you maintain the benefits long after you stop therapy.  


When Is The Best Time To Start?


  • Injections or sublingual drops take several months to start working and can take up to a year or more to reach full efficacy.  Starting months before your peak allergy season is ideal, but injections can be started at any time of the year. 


  • Patients 3 years of age and older are candidates.


Is Immunotherapy Covered By Insurance? 


  • Injections are typically covered by insurance, though the cost to you will be determined by your specific plan and your deductible. We can provide general pricing information. 


  • Sublingual drops are unable to be billed to insurance. Costs are Out of Pocket and range from $85 to $145 per month. Additional information can be found here.


How Often Are Office Visits?


  • The first injection or sublingual dose will require an office visit, but all other injection visits are walk-in without an office visit. After the first dose, injections are not scheduled. You are not assigned a designated day or time. You may come at your convenience during our shot hours (Injection Calendar). 


  • There will be routine visits during the build-up phase of injections or sublingual drops. After the goal dose is reached, office visits are required at least once annually.  


What If I Will Be Out Of Town Or Miss Injections?


  • If you miss an injection or are late for an injection, a dose adjustment will be made if needed. Injections would typically only need to be restarted if there was a very prolonged gap between injections.


  • If you anticipate a number of missed doses or problems coming in for injections, sublingual drops may be a more convenient option for you. 


What Are Next Steps If I Wish To Start Injections or Drops? 


  • Discuss your history and goals directly with your provider during a visit. 


  • Once you and your provider have decided on a treatment plan, please complete and return the consent forms. After the consent forms are received, your vials will be mixed and we will contact you to schedule your first dose. Please allow at least 2 weeks for mixing. For sublingual drops, payment must be received prior to mixing.  NOTE: Please do NOT return the consents unless you are certain you want to start IT, as vials are mixed once the consents are received.


Special Circumstances


  • Injections or sublingual drops should not be started if you are pregnant. If you are on injections or drops and become pregnant, you will be held at your current dose for the duration of your pregnancy. 


  • You should tell your provider if you are on a medication called a Beta Blocker. This class of medications is prescribed for conditions such as high blood pressure, migraines, tremors and anxiety. Examples include propranolol, atenolol and metoprolol. 


  • Out of office administration of injections by a medical professional is permitted in specific circumstances, for example when a patient on injections is away at college. An “Off Site Injection” policy will apply. 


Immunotherapy Options At a Glance


InjectionsSublingual  Drops
Location OfficeHome
AdministrationInjected into armLiquid administered under tongue
EfficacyExcellent Good
Multiple AllergiesBestFair/Good 
Side EffectsLocal reactions. 

Systemic reactions uncommon 

(< 0.1%).

Itchy mouth/throat. 

Systemic reactions very uncommon. 

Frequency Of DosingEvery 1-4 weeks per protocol 

(weekly to start)

FDA ApprovedYesNo
Insurance CoverageYesNo
CostWill depend on insurance$85 – $145 per month


 Harold S. Nelson, MD; Subcutaneous Immunotherapy Versus Sublingual Immunotherapy: Which is More Effective? Journal of Allergy and Clinical Immunotherapy, April 2014

2022 End of Year Allergy Shot Extract Reorders

It’s that time of the year again! If you are on allergy shots and would like to reorder your allergy extract in this (2022) calendar year so that it can be billed to insurance before 2023, we must receive your order by Friday, December 16, 2022. Any orders placed after that date cannot be completed or billed until January 2023. Guidelines for reorder prior to year-end:


To order extract before year-end, please either:

  • Send us a message through your Patient Portal Account with “Allergy Extract Refill” in the subject line.
  • Make the request when getting your shots by the December 16th deadline.

Patients on subcutaneous (allergy shots) or sublingual (allergy drops) allergen immunotherapy must be seen at least once every 12 months to allow your provider to assess your response to treatment. If you have not had a visit this year, it is a good time to schedule your annual appointment and maximize your 2022 insurance benefits and/or flexible spending accounts.

What Is Food OIT and Sustained Unresponsiveness?

This is a great question! As many of you reading this likely know, oral immunotherapy (OIT) is a desensitization process for treatment of peanut and other food allergies. You can think of oral desensitization as what Dread Pirate Roberts (Westley) did with iocane powder- a colorless, odorless, and deadly poison from Australia.

Westley spent two years building up a tolerance to iocaine powder by ingesting increasing amounts of it, so it would not hurt him. He uses this protection to defeat Vizzini in their battle of wits!


Early OIT for peanut has been shown to be ~98% effective for infant to toddler aged kids while only 20-30% of kids otherwise outgrow peanut allergy. A multicenter study published by Jones et al., in Lancet in January 2022 looked at 146 kids 1-4 years-old who either received a maintenance OIT peanut dose equivalent to ~ 8 peanuts daily (96 kids) or placebo (50 kids).

After more than 2 1/2 year of OIT, 68 of the 96 (71%) on OIT could tolerate a challenge equivalent to about 20 peanuts compared to 1 of the patients (2%) on placebo. So, even if kids could not tolerate the ~20 peanut equivalent challenge, they were still able to tolerate ~8 peanut equivalent once daily.


The primary goal of OIT is to reduce the risk of an anaphylactic (life threatening) reaction due to an accidental food exposure, but the odds are excellent there is even greater benefit! Twenty-one percent of kids in the study who had reached a maintenance peanut OIT dose were able to tolerate about 20 peanuts even after discontinuing OIT for over 6 months. They had achieved SUSTAINED UNRESPONSIVENESS (SU) or what can be thought of as REMISSION from their peanut allergy!

The percentage who achieve remission seems to go up significantly when the SU challenge is done after 4 weeks of avoiding the food (usually after a few years of OIT). In a study by Vickery et al., published in The Journal of Allergy & Clinical Immunology in January 2017, the success rate for achieving remission for children 9-36 months of age was over 90% for those who completed the protocol for peanut. Once someone achieves remission by passing a SU challenge, then they should no longer need to have access to epinephrine for that particular food!


Together, these studies show that starting peanut OIT before 4 years of age increases the likelihood of achieving both desensitization AND remission, suggesting a window of opportunity at a young age for treatment of peanut allergy!

That is not to say that older kids cannot be successfully desensitized. In fact, our first patient was desensitized at 9 years of age, and is now nearly 16 years-old and doing very well! We have also had teenagers and adults successfully achieve a maintenance dose of OIT.

While these studies focus on peanut, the same outcomes likely hold true when using OIT to treat other food allergies, such as milk/dairy, eggs, tree nuts, soy, and sesame. Our team is constantly working hard to provide the safest and most effective treatment opportunities for our food allergy patients! If you are interested in learning more about OIT, schedule a visit with one of our providers. You can do so here:


You can also read more about OIT on our Food Allergy Center page.


We also recommend you read or see the Princess Bride if you haven’t already!

2021 Year End Allergy Extract Orders


If you are on allergy shots and would like to reorder your allergy extract in this calendar year so that it can be billed to insurance before 2022, we must receive your order by Friday, December 17, 2021. Any orders placed after that date cannot be completed or billed until January 2022. Guidelines for reorder prior to year-end:


To order extract before year-end, please send us a message through your Patient Portal Account with “Allergy Extract Refill” in the subject line.

Patients on allergen immunotherapy (allergy shots) must be seen at least once every 12 months to allow your provider to assess your response to treatment. If you have not had a visit this year, it is a good time to schedule your annual appointment and maximize your 2021 insurance benefits and/or flexible spending accounts.

Hay Fever: Fact or Fiction

You can almost set your clock to it – winter ticks over into spring, plants start to bloom, and people’s noses start to act up – runny nose, stuffy nose, or even post-nasal drainage. The condition commonly called “seasonal allergies” or “hay fever,” which goes by the medical name of “Allergic Rhinitis,” affects up to 60 million people in the United States and can make life a snotty mess. Read below to learn more about this condition, including some common misconceptions.

Fact or Fiction: Seasonal allergies are called that because they only occur in the spring and the fall

FICTION. “Seasonal allergies” can be a bit of a misnomer. While it is certainly common to have flares of symptoms in the spring and fall, many people suffer from perennial (year-round) symptoms. This can occur because of allergies to indoor allergens like dogs, cats, cockroaches, and dust mites. Allergy testing can evaluate for the commonly known allergens like trees, grasses, weeds, and molds and tests for indoor allergens. Unfortunately, many people can’t count on the time of the year to provide relief.

Fact or Fiction: Eating local honey helps prevent or treat nasal allergy symptoms.

FICTION. This commonly suggested remedy offers to provide allergy relief with a tasty treat. Sadly, it is not effective. The thought process is that local honey contains pollen, and eating the honey will allow for exposure to the pollen – similar to an allergy shot. While there can be small amounts of pollen in local (unprocessed) honey, this tends to be from flowering plants, which are less likely to cause allergy symptoms. Pollen allergy is most commonly caused by wind spread pollens like those from grasses, trees, and weeds. 

Fact or Fiction: Allergies aren’t the only cause of this type of nasal symptom.

FACT. Though ⅓ of patients with persistent nasal symptoms have allergic triggers, another ⅓ have non-allergic triggers. These triggers can include perfumes/fragrances, smoke, or even temperature/humidity changes; the latter two can mimic the seasonal pattern seen in seasonal allergies. Thus, the final ⅓ of patients with nasal symptoms have a combination of allergic and non-allergic triggers, which we call “mixed rhinitis.”

Fact or Fiction: Allergic (or non-allergic) nasal symptoms are just a normal part of life that has to be dealt with – there’s nothing to be done about them.

FICTION. Thorough evaluation of symptoms, combined with allergy testing, helps guide specific treatment for your nose symptoms. At Allergy, Asthma & Food Allergy Centers, we are experts in diagnosing and treating allergic, non-allergic, and mixed nasal symptoms. A combination of environmental control measures (to reduce exposure to allergens), treatment with oral or nasal medications, and possibly the addition of allergen immunotherapy (allergy shots) can provide lasting symptom relief.

Allergists are uniquely qualified to help you get the relief you need when it comes to this troublesome condition. You can learn more about this condition in our blog, or by making an appointment to be seen by one of our providers.

Welcome Dr. Waterhouse

We are also excited to welcome Dr. Waterhouse to our AAFAC team! After graduating from medical school at UMKC, Dr. Waterhouse returned to St. Louis and did a pediatric residency at Cardinal Glennon Children’s Hospital.

She completed her allergy and immunology fellowship at SLU, and after finishing her fellowship, she started the allergy department at SSM Medical Group, where she has worked for the past 10 years. Dr. Borts and Dr. Warrier were Dr. Waterhouse’s mentors during her fellowship, and she is honored to practice and work with them again. She’s also excited to offer her patients OIT for those suffering from food allergies. Dr. Waterhouse will mainly be seeing patients in west county in the Chesterfield office at Clarkson and Baxter.

Welcome Dr. Dixit

We are pleased to welcome Dr. Dixit to our team of providers! 

He grew up on the Mississippi Gulf Coast and went to Millsaps College in Jackson, MS. Dr. Dixit stayed in Jackson for medical school at the University of Mississippi School of Medicine and completed his internal medicine training at the University of Mississippi Medical Center. He decided to pursue allergy and immunology and completed his fellowship at Saint Louis University.

Dr. Dixit is excited to be joining the team, and will mainly be seeing patients in the Swansea, Illinois office.

Q & A with Laura Kahle, PA-C

Q: How long have you worked at AAFA Centers?

A: I have worked at AAFA Centers for 4 years- and a lot has changed over that time! Three new offices and many new medical services. It’s been an amazing experience to be part of the growth.

Q: What inspired you to be a physician assistant? 

A: I am also a Registered Dietitian and previously worked in pediatrics (particularly Cystic Fibrosis). I wanted to be able to provide complete medical care and not only nutrition therapy. One of the pulmonologists I worked with encouraged me to pursue Physician Assistant studies. I wanted to work in a field where I could utilize my nutrition and PA background, so here I am!

Q: What do you like to do in your free time? 

A: Pre-COVID, we traveled all over the country to see friends and family and explore the outdoors. Now, my husband and I have gotten a little more creative to keep exploring the local outdoors with our 2 little girls.


Welcome Patients of Dr. Kim Waterhouse to Allergy, Asthma & Food Allergy Centers

Dear Dr. Waterhouse Patients,

We are delighted to welcome you to our practice! We aim to make your transition as smooth as possible. 

If you are on allergy injections, we should have your vials by July. Please download the new patient paperwork from this page and allergy shot treatment consent and financial consent. We do ask that you please email the completed new patient paperwork, consent forms, copies of the front and back of your insurance card, and driver’s license to Please include in the subject line “transferring Dr. Waterhouse patient”. Please also schedule an in person office visit at your earliest convenience in order to become further established in our practice. You will need to have that visit before we can refill medications and answer medical questions. The first visit will likely be with Lauren Davis, PA-C in the Chesterfield office, but Dr. Waterhouse will resume her role as your primary Allergist after she starts with the practice in late August. 

  • Allergy injections administered in our Chesterfield office (16216 Baxter Rd., Suite 299, Chesterfield, MO 63017):
    •  8:30AM – 4:30PM Mon-Thur
    •  8:30AM – 2:30PM Fri
    • We plan to add late office hours starting Tuesday, August 31, 2021.
  • We follow the guidelines from our professional allergy societies  that all allergy injection patients will need to wait in the office for 30 minutes after their injections.

If you are on a biologic for asthma or hives (ex. Xolair, Fasenra, Nucala, Cinqair, or Dupixent), please call at your earliest convenience to schedule a telemedicine or in person office visit by June 2021. If this is a telemedicine visit, it will be with one of our Advanced Practice Providers (Lauren Davis, PA-C, Laura Kahle, PA-C, or Dani Loftus FNP-BC) so we can get you established as soon as possible. You can read more about telemedicine visits here. This will allow us to get you registered in the practice and enable us to go through the necessary prior authorization process to obtain your medications. When you are due for your injection(s), and we have verified that we have your medication, we will schedule an in person visit in the office. Please note that our policy is that you will need an office visit for each biologic injection administered in the office. New Patient paperwork is available on this page and information on telemedicine visits is available here. Email the completed new patient paperwork, consent forms (if needed), copies of the front and back of your insurance card, and driver’s license to Please include in the subject line “transferring Dr. Waterhouse patient”.

For all other patients, we request that you please schedule a telemedicine or in person office visit at your earliest convenience to become established in our practice. We will need to see you to get you established in our system so we can refill medications and answer any medical questions. This is also an excellent time to do an annual visit. We can provide updated food allergy and asthma action plans at the time of the visit if needed. New Patient paperwork is available on this page and information on telemedicine visits is available here. Email the completed new patient paperwork, consent forms, copies of the front and back of your insurance card, and driver’s license to Please include in the subject line “transferring Dr. Waterhouse patient”.

We recommend that you follow us on Facebook, where we post practice updates.

It is our pleasure to play a role in keeping you well. We look forward to meeting you!

Telemedicine Still Available in 2021

Allergy, Asthma & Food Allergy Centers has been using the platform for telemedicine visits since Thursday, March 19, 2020, and this has worked very well for patients unable to come to one of our physical locations (Swansea, Illinois; Bloomsdale/Ste. Genevieve, Missouri; South County/Sunset Hills, MO; and West County/Chesterfield, MO). 

Telemedicine Frequently Asked Questions:

  1. How does telemedicine work?
    1. A staff member will call you in the morning on the day of your scheduled appointment to collect insurance information and copays.
    2. You will receive a text in most cases (an email if you cannot receive texts or prefer to do the visit using a computer/laptop/tablet) with a link from You can watch a brief instructional video here and/or review this document.
    3. Open the link through your phone or use Chrome browser when on a computer/laptop. You will need a strong internet connection and will need to give permission for the website to use your camera and microphone.
    4. Sign in with the patient’s first and last name and click the “Check In” box, which will place you in the virtual waiting room. You can also review the telemedicine consent and test your connection while in the waiting room.
    5. Once the visit has started, your provider will be able to see you, and you will be able to see them. Your provider may not always be looking at the camera, because they will have another screen open with your medical record so they can document and review your information. Please be assured that if the provider looks away, they are not being distracted from the visit, and your medical care is their sole focus during your appointment.
  2. Do I need to download any program or application?
    1. No, because the platform is web-based, you can access it from a browser on an internet connected device.
  3. What type of device do I need?
    1. You need an internet connected smartphone, tablet, computer, or laptop that has a camera and microphone. You will have to give the camera and microphone permission to access your web browser, which you should be able to do in the settings of your device, and we recommend you confirm this before your appointment.
  4. What else should I do to prepare for the visit?
    1. If you have a thermometer, please take your temperature before the visit to let the provider know so they can document it in your chart.
    2. Please take your pulse manually (instructions here) or with an apple watch, fitbit, or other device before the visit and let your provider know so they can document it in your chart.
    3. You can also review the telemedicine consent form here.
  5. Is the telemedicine visit secure?
    1. Yes, the telemedicine platform is secure and HIPAA compliant.
  6. What if I do not receive a text or an email?
    1. If it is 5 minutes past your scheduled appointment and you have not received a text or email, please call our office.
  7. Is telemedicine more expensive than an office visit?
    1. No, you will have the same copay as you would with an in person office visit, but you do not have to leave the comfort of your home.
  8. What if my primary allergist is not available for a telemedicine visit?
    1. Do not worry! Our fantastic advanced practice providers, Lauren Davis, PA-CLaura Kahle, PA-C, or Dani Loftus, FNP-BC can see you if your primary allergist is not available.