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.

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.

Seasonal and Year-Round Allergies (Allergic Rhinoconjunctivitis)

Outdoor Allergens 

Seasonal allergic rhinitis, commonly referred to as hay fever, affects millions of people worldwide. Symptoms include sneezing, nasal congestion, runny nose, and itchiness in your nose, the roof of your mouth, throat, eyes, or ears. The most common seasonal triggers are pollen and mold spores in the air, which trigger a chain reaction in your immune system.

Your immune system controls how your body defends itself. For instance, if you have an allergy to pollen, the immune system identifies pollen as an invader or allergen. Your immune system overreacts by producing antibodies called Immunoglobulin E (IgE). These antibodies travel to cells that release chemicals, causing an allergic reaction.


Pollen consists of tiny grains needed to fertilize many kinds of plants. Pollen from plants with colorful flowers, like roses, usually do not cause allergies. These plants rely on insects to transport the pollen for fertilization. On the other hand, many plants have flowers that produce powdery pollen that is easily spread by wind. These culprits cause allergy symptoms.

Each plant has a period of pollination that does not vary much from year to year. Trees pollinate in the spring, grasses in the early summer, and weeds in the late summer/fall. In the St. Louis area, major trees causing symptoms in the spring are oak, ash, and mulberry. Ragweed is a major fall allergen, which typically causes symptoms around Labor Day. The weather can affect the amount of pollen in the air at any time. In warmer places, pollination can be year-round.


Molds are tiny fungi related to mushrooms but without stems, roots or leaves. Molds can be almost anywhere, including soil, plants, and rotting wood. Their spores float in the air, much like pollen. Outdoor mold spores begin to increase as temperatures rise in the spring. In the United States, mold spores reach their peak in July in warmer states and October in the colder states. They can be found year-round in the South and on the West Coast.

Pollen and Mold Levels

Pollen and mold count measures the number of allergens present in the air. The National Allergy Bureau is the nation’s only pollen and mold counting network certified by the American Academy of Allergy, Asthma & Immunology (AAAAI). The NAB compiles pollen and mold levels from certified stations across the nation. You can find these counts for different geographic areas here. Counts for St. Louis can be found at the St. Louis County Pollen and Mold Center.

Effects of Weather and Location

The severity of your symptoms may be affected by recent contact with other allergens, the amount of pollen exposure, and your sensitivity to pollen and mold. Hay fever symptoms are often less prominent on rainy, cloudy, or windless days because pollen does not move around during these conditions. Pollen tends to travel more with hot, dry, and windy weather, which can increase your allergy symptoms.


If your seasonal symptoms are making you miserable, we can help!

As board-certified allergists, we have the background and experience to determine which allergens, if any, are causing your symptoms. This information will form the basis of a personalized treatment plan to help alleviate your symptoms, including recommendations on how to avoid or minimize contact with your allergens where possible.

If your symptoms continue or if you have them for many months of the year, you may benefit from allergy immunotherapy (allergy shots). This treatment involves receiving regular injections given in gradually increasing doses. This helps your immune system become more resistant to the specific allergen and lessen your symptoms as well as the need for medications.

There are also simple steps you can take to limit your exposure to the pollen or molds that cause your symptoms:


  • Keep your windows closed at night and if possible, use air conditioning, which cleans, cools, and dries the air.
  • Try to stay indoors when the pollen or mold counts are high. If your symptoms are severe, wear a pollen mask if long periods of exposure are unavoidable. When you return indoors, take a shower, shampoo your hair and change clothes.
  • Avoid being responsible for mowing lawns or raking leaves. This stirs up pollen and molds. Also, avoid hanging sheets or clothes outside to dry.
  • When traveling by car, keep your windows closed.
  • Take any medications as prescribed.
  • Avoiding exposure during times of high pollen and mold counts will help ease symptoms.
  • The majority of hay fever medications work best if started before a pollen season begins. For spring allergies, we typically recommend starting medications around Valentine’s Day.
  • Allergy shots can often provide long-term relief of hay fever symptoms.



Indoor Allergens

Millions of people suffer year-round from allergy symptoms caused by indoor allergens. These culprits include dust mite droppings, animal dander, cockroach droppings, and molds.

When allergy symptoms occur year-round, the condition is called perennial allergic rhinitis. In addition to causing allergy symptoms, allergens can also trigger asthma flare-ups in people with allergic asthma.

Dust mites

Dust mite allergens are a common trigger of allergy and asthma symptoms. While they can be found throughout the house, these microscopic creatures thrive in warm, humid environments such as bedding, upholstered furniture, and carpeting.

Because so much time is spent in the bedroom, it is essential to reduce mite levels there. Encase mattresses, box springs, and pillows in special allergen-proof fabric covers or airtight, zippered plastic covers. Bedding should be washed weekly in hot water (130° F) and dried in a hot dryer. Allergen-proof covers are available for comforters and pillows that can’t be regularly washed.

Keep humidity low by using a dehumidifier or air conditioning. Wall-to-wall carpeting should be removed as much as possible. Instead, throw rugs may be used if they are regularly washed or dry cleaned.

Pet Allergens

There are no truly “hypoallergenic” breeds of dogs or cats. That is because people are not allergic to an animal’s hair, but to an allergen found in the saliva, dander (dead skin flakes), or urine of an animal with fur. While there are no cats and dogs that do not produce allergens, the amount of allergen exposure from pets may vary somewhat depending on the breed.

Pet allergy symptoms typically occur within minutes, with short-term exposure. With more chronic exposure symptoms may occur more chronically and not as acutely. For some people, symptoms build and become most severe 8 to 12 hours after contact with the animal. People with severe allergies can experience reactions in public places if dander has been transported on pet owner’s clothing.

If you have a pet that you are allergic to, try to minimize contact and keep the pet out of the bedroom and other rooms where you spend a great deal of time. As with dust mites, vacuum carpets often or replace carpet with a hardwood floor, tile, or linoleum. Keeping an animal outdoors is only a partial solution since homes with pets in the yard still have higher concentrations of animal allergens. If you have a cat allergy, there is a specific cat food that can decrease to some extent the amount of allergen produced by cats. You can read about that here Pro Plan LiveClear Allergen Reducing Cat Food.

While dander and saliva are the sources of cat and dog allergens, urine is the source of allergens from rabbits, hamsters, mice, and guinea pigs; so ask a non-allergic family member to clean the animal’s cage.

If you have a pet allergy, allergy immunotherapy (allergy shots) could be a great option! This strategy can often provide significant and long-term relief.


Cockroaches are often found in the homes of densely populated urban areas, schools, or commercial buildings, but these creatures can lurk almost anywhere. This does not mean that you have a dirty house or living area.

Block all areas where roaches can enter the home. This includes crevices, wall cracks, and windows. Cockroaches need water to survive, so fix and seal all leaky faucets and pipes. Have an exterminator go through the house when your family and pets are gone to eliminate any remaining roaches.

Keep food in lidded containers and put pet food dishes away after your pets are done eating. Vacuum and sweep the floor after meals, and take out garbage and recyclables. Use lidded garbage containers in the kitchen. Wash dishes immediately after use and clean under stoves, refrigerators, or toasters where crumbs can accumulate. Wipe off the stove and other kitchen surfaces and cupboards regularly.

Indoor Molds

Indoor molds and mildew need dampness typically found in basements, bathrooms, or anywhere with leaks. Get rid of mold growth on hard surfaces with water, detergent and, if necessary, 5% bleach (do not mix with other cleaners). Then dry the area completely. If mold covers an area of more than 10 square feet, consider hiring an indoor environmental professional. For clothing, washing with soap and water is best. If moldy items cannot be cleaned and dried, throw them away.

Repair and seal leaking roofs or pipes. Using dehumidifiers in damp basements may be helpful, but empty the water and clean units regularly to prevent mildew from forming. All rooms, especially basements, bathrooms, and kitchens, require ventilation and cleaning to deter mold and mildew growth. Avoid carpeting on concrete or damp floors, and storing items in damp areas.


Welcome patients of Dr. Esswein to Allergy, Asthma & Food Allergy Centers!

Dear Dr. Esswein Patients,

We are delighted to welcome you to our practice! While we did not anticipate this particularly trying time, we aim to make your transition as smooth as possible. 

If you are on allergy injections, we should now have your vials. Once we have entered your vials into our electronic system and have you registered in the practice, we will call to let you know that you can come for your injections.  Please wait for this call before you come to our office, but in the meantime, please download the new patient paperwork from this page and allergy shot treatment consent and financial consent. 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. Esswein patient”. If you have not received a phone call in the next 1-2 weeks, please call us. Please also schedule a telemedicine 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 telemedicine visit will be with Dr. Esswein or 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.

  • Allergy injections are administered:
    •  8:30AM – 4:30PM Mon-Thur
    •  8:30AM – 2:30PM Fri
    • You will notice we have shot hours on Tue evenings (not currently offered during the COVID-19 pandemic) and Sat mornings. We ask that you kindly avoid these times until further notice, as they are typically our busiest times with the longest wait periods. 
  • 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.
  • During this time of concern for COVID-19, we will not escalate your dose. This is to help minimize the risk of an adverse reaction, particularly as we are now in the spring season. We will also allow you an extra week “grace period” where you will not be considered late. 

If you are on a biologic for asthma or hives (ex. Xolair, Fasenra, Nucala, Cinqair, or Dupixent), please call to schedule a telemedicine visit at your earliest convenience. 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, copies of the front and back of your insurance card, and driver’s license to Please include in the subject line “transferring Dr. Esswein patient”.

For all other patients, we request that you please schedule a telemedicine visit at your earliest convenience to become established in our practice. We will need to see you for the telemedicine visit in order to refill medications or 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. Esswein patient”.

We recommend that you follow us on Facebook. We will be posting practice updates, particularly as we do our best to navigate the challenges posed by COVID-19. 

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

Telemedicine Services Available!

Allergy, Asthma & Food Allergy Centers has been using the platform for telemedicine visits since Thursday, March 19, 2020, and this has been working very well for patients at all of our current locations (Swansea, Illinois; Bloomsdale/Ste. Genevieve, Missouri, and south county). Telemdicine appointments can also be done for those currently scheduled to be seen in our Chesterfield (west county) location at 16216 Baxter Rd. Suite 299, Chesterfield, MO 63017. As you know, we have moved most of our patients to telemedicine visits in the interest of public safety to decrease the spread of COVID-19 in our community while continuing to provide essential medical care.

If you are scheduled for any upcoming office visits, other than for biologic medication administration, our staff will continue to contact you before your appointment to convert your appointment to a telemedicine visit. The telemedicine visits enable new and established patients to keep their originally scheduled visits to discuss medical problems, treatment plans, allergy shots, and prescription medications while following the “stay at home” rules. These visits will be increasingly important for patients and families as the spring tree pollen season ramps up. The spring pollen season gets busy, and appointments can be scarce in the greater St. Louis area, but Allergy, Asthma & Food Allergy Centers has 8 active providers who are able to see patients via telemedicine even during these troubled times. Call 314-849-8700 or 618-233-8700 to schedule your telemedicine visit to help you stay healthy during this allergy season.

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. I have read that insurance companies are waiving copays for telemedicine visits, so why do I have a copay?
    1. Insurance policies vary on this. If your insurance pays for the telemedicine visit, including the cost of the copay, you will receive a refund. You should be able to determine this by the explanation of benefits (EOB) that you will eventually receive from your insurance company.
  9. What if my primary allergist is not available for a telemedicine visit?
    1. Do not worry! Our fantastic advanced practice providers, Lauren Davis, PA-C, Laura Kahle, PA-C, or Dani Loftus, FNP-BC can see you if your primary allergist is not available.

Singulair (montelukast) Black Box Warning

On March 4, 2020 the U.S. Food & Drug Administration (FDA) decided to add a “Boxed Warning” to the oral medication montelukast (brand name, Singulair) due to an elevated concern regarding the risk of neuropsychiatric events, including suicidal thoughts and actions. Because of this new warning, the FDA is now recommending that montelukast only be used to treat patients with allergic rhinitis and asthma that do not tolerate or do not respond to alternative medications.

Montelukast is a leukotriene receptor antagonist that has been used to treat patients with asthma, allergic rhinitis and other conditions such as chronic urticaria (hives) since the drug was approved in the U.S. in 1998. There were no major reported safety concerns with this drug until 2007, when the manufacturer of Singulair updated the prescribing information and patient information to include post-marketing adverse events such as behavior/mood changes (i.e. agitation, anxiety, depression) and suicidality (suicidal thinking and behavior). 

Data collected by the FDA between 1998 and 2019 through their Adverse Event Reporting System identified 82 cases of completed suicide in patients taking montelukast, with 19 cases in patients under age 18. Interestingly, further data from the FDA’s Sentinel System collected between 2010 and 2015 did not show an increased risk of neuropsychiatric events in approximately 450,000 asthmatics older than age 6 taking montelukast vs. inhaled corticosteroids. Other observational studies also did not find an increased risk of mental health side effects. That being said, the reports of suicide along with evidence that montelukast crosses the blood-brain barrier in animal models persuaded the FDA to strengthen their warning.

Our medical providers at Allergy, Asthma & Food Allergy Centers are dedicated to providing the best possible treatment options for our patients while also keeping their safety in mind. Although the overall prevalence of severe neuropsychiatric events including suicide appears to be extremely low given the number of patients in the U.S. taking montelukast, we understand that our patients and caregivers may be hesitant to start or continue taking this medication. If you are already taking this medication it is safe to stop immediately, if you are not comfortable continuing it. However, we strongly advise that you contact our office to schedule an appointment to discuss alternative treatment options. As with any medication, either prescription or over-the-counter, we are more than happy to discuss the risks and benefits with you. If you are not having any problems while on montelukast, it is likely safe to continue the medication.