Gastroesophageal reflux disease (GORD) is an often debilitating condition characterised by retrograde flow of content from stomach into the oesophagus, where the low pH of the stomach acid irritates the mucosa of the oesophagus. The most dominant symptoms in GORD are pyrosis, regurgitation, and dysphagia. Sublingual immunotherapy (SLIT) was first described in 1986. Following this description, the use has greatly increased in the treatment of allergic rhinitis, as an alternative to subcutaneously administered immunotherapy. Side effects are commonly of oropharyngeal and gastrointestinal nature, for example, swelling, itching, irritation, ulceration of the oropharynx and nausea, abdominal pain, vomiting, and diarrhoea. More serious side effects are dominated by respiratory tract and systemic manifestations. A 30-year-old male experienced refractory, relentless, and debilitation GORD subsequent to administration of sublingual immunotherapy for house dust mite in allergic rhinitis. The patient had to stop the SLIT after two weeks of administration due to GORD. The cessation resulted in rapid resolution of symptoms.
Allergen immunotherapy has traditionally been administered by subcutaneous injections, but regular injections for a period of 3–5 years are often required for efficacy. Conversely, sublingual immunotherapy (SLIT) first described in 1986 [
A 30-year-old male with no history of gastroesophageal disease and with known allergic rhinitis due to HDM (
Gastroesophageal reflux is a debilitating symptom and may be classified as GORD if the extent of the symptoms is high enough. The most dominant symptoms are pyrosis, dysphagia, and regurgitation [
Gastroesophageal reflux is to some extent considered a physiological process, as it often occurs transiently in the postprandial state. Thus, most people experience intermittent or transient gastroesophageal reflux; however, only a smaller proportion fulfils the criteria for diagnosis; hence, in a predominantly Western population the prevalence is found to be between 10 and 20 percent [
The most common risk factors of gastroesophageal reflux are hiatus hernia, smoking, certain types of food (i.e., high in saturated fat) and eating pattern, and obesity [
An alternative and perhaps more plausible explanation of the refractory symptoms of primarily pyrosis in this patient could be eosinophilic esophagitis (EO), that is, an immune system disease that is characterised by persistent heartburn, upper abdominal pain, and regurgitation refractory to medication, for example, proton pump inhibitors and antacids [
In relation to SLIT, no previous reports of GORD as side effect have been identified; hence, this is the first report per se; although the symptoms may be attributed to EO, a diagnosis of EO cannot be made retrospectively. The low incidents of GORD or GORD because of EO may be due to GORD being a frequently reported symptom in any population and therefore not regarded as a problem by the individual, underreporting, or very low incidence of GORD due to SLIT.
A short escalation in dose could potentially circumvent the initial side effects; AZARIZAX is, however, only available in 12 SQ-HDM, but other SLIT products are also available. Taken together, the pathophysiological mechanisms of monosymptomatic GORD induced by SLIT with HDM allergen remain unknown, as none of the enumerated causes fit the current case. Relaxation of the lower oesophageal sphincter because of mild allergic/asthmatic reaction due to SLIT allergens may provide a theoretical explanation.
The details of this case provide important insights for clinical practice, as GORD has not previously been reported as a side effect of SLIT with HDM allergens. Although side effects may occur, SLIT remains safe and efficacious. Informing patients receiving SLIT remains important when prescribing SLIT and should include information regarding risks of both local and systemic side effects including GORD and the risk of change of treatment from SLIT to, for example, subcutaneously administered immunotherapy, due to side effects such as GORD. Contrarily, if a diagnosis of EO is more probable, the treatment protocol of this disease should be followed.
The author has no conflicts of interest to declare.