Introduction and scope (dated December 18, 2025)

This directory‑style explainer clarifies who typically provides allergen immunotherapy in the United States, with a focus on sublingual immunotherapy (SLIT). It contrasts delivery options—subcutaneous immunotherapy (SCIT, “allergy shots”), FDA‑approved SLIT tablets, and SLIT liquid drops—and outlines which clinician types offer each modality, where care is delivered, and key safety requirements. Citations emphasize consensus resources from AAAAI, ACAAI, and AAO‑HNS.

Quick reference: modalities, settings, and who provides them

Who provides each option—and how care is structured

1) Allergy shots (SCIT)

• Providers and setting: SCIT is generally prescribed and supervised by board‑certified allergists/immunologists; some otolaryngologists also administer immunotherapy within ENT practices. Injections are administered in a medical office with trained staff and immediate access to epinephrine and airway support. The standard observation period is at least 30 minutes after each injection because most severe reactions occur within that time window. AAO‑HNS Clinical Practice Guideline on Immunotherapy for Inhalant Allergy.

• Safety and monitoring: National surveillance data from AAAAI/ACAAI support the 30‑minute observation recommendation and reinforce risk‑reduction measures (e.g., defer injections in uncontrolled asthma). PubMed summary of AAAAI/ACAAI surveillance.

• Role of guidelines: The Joint Task Force (AAAAI/ACAAI) practice parameters and AAO‑HNS clinical guidance describe patient selection, dosing, and clinic preparedness for anaphylaxis. AAAAI JTF parameters index.

2) SLIT tablets (FDA‑approved)

• What’s approved: In the United States, four daily tablets are FDA‑approved—ragweed (Ragwitek), two grass formulations (Grastek, Oralair), and house dust mite (Odactra). Indicated ages and start‑times vary (e.g., grass and ragweed tablets generally start 12–16 weeks before season; dust mite is year‑round). AAAAI drug guide.

• First dose in office: For safety, the first tablet dose is administered under clinician observation for at least 30 minutes; patients are prescribed an epinephrine autoinjector for home use. Subsequent dosing is done at home. AAAAI patient page.

• Who prescribes: Allergists/immunologists most commonly prescribe SLIT tablets; other physicians with relevant training may prescribe and supervise care in accordance with practice parameters. AAAAI practice parameters.

3) SLIT liquid drops (off‑label in the U.S.)

• Regulatory status: In the U.S., SLIT drops for environmental allergens are not FDA‑approved; their use relies on off‑label administration of FDA‑licensed allergen extracts. Patients should receive informed consent about off‑label status and evidence. ACAAI overview of SLIT.

• Who offers drops: Some allergists and otolaryngologists offer SLIT drops for carefully selected patients following practice parameters and institutional protocols, particularly when injections are impractical or tablets do not match a patient’s allergen profile. Guidance on immunotherapy, including SLIT considerations, is provided by the Joint Task Force and AAO‑HNS guideline documents. AAAAI practice parameters, AAO‑HNS CPG landing.

Clinician types and typical roles

• Allergists/immunologists: Fellowship‑trained physicians (after internal medicine or pediatrics residencies) with ABAI board certification; they most commonly diagnose allergic rhinitis/asthma and deliver SCIT or SLIT. AAAAI: About Allergists/Immunologists.

• Otolaryngologists (ENTs): Surgeons and medical specialists who manage nasal/airway disease; many provide allergy testing and immunotherapy, often following AAO‑HNS clinical practice guidelines for allergic rhinitis and immunotherapy. AAO‑HNS guideline page, AAO‑HNS Immunotherapy CPG (open‑access summary).

• Primary care (pediatrics, family medicine, internal medicine): May identify candidates, initiate referral, and co‑manage care; in some settings they prescribe SLIT tablets with specialist collaboration. Professional societies recommend that patients be accurately diagnosed and risk‑stratified, and that first tablet doses be observed in a medical setting. AAAAI overview of tablets.

• Advanced practice clinicians (NPs/PAs): Commonly participate in allergy practices under physician supervision, including administering SCIT and monitoring post‑dose observation per protocol, consistent with clinic policies and state scope‑of‑practice laws. Guidance on immunotherapy administration and monitoring is detailed in society guidelines. AAO‑HNS Immunotherapy CPG (scope includes all clinicians).

Safety requirements and observation

• SCIT: Observe patients in the clinic for at least 30 minutes post‑injection; most severe reactions occur in this period, though delayed systemic reactions can occur. Clinics maintain trained staff and anaphylaxis protocols. AAO‑HNS open‑access summary, AAAAI/ACAAI surveillance.

• SLIT tablets: First dose is observed (≥30 minutes), and an epinephrine autoinjector is prescribed for at‑home use. AAAAI.

• SLIT drops: Clinics document off‑label use and follow risk‑mitigation practices consistent with immunotherapy parameters; patients receive education on adverse reactions and when to seek care. ACAAI, AAAAI parameters index.

Telehealth and SLIT

• What can be done virtually: Telehealth is well‑suited for evaluation of allergic rhinitis/asthma history, environmental control counseling, follow‑up, adherence support, and at‑home SLIT maintenance (tablets after the supervised first dose; off‑label drops per clinic protocol). Hybrid models (in‑person plus virtual) are supported by allergy telehealth literature. JACI‑In Practice telehealth review.

• What must remain in‑person: SCIT injections and the first SLIT‑tablet dose (with 30‑minute observation) require in‑office administration and monitoring. AAAAI tablets, AAO‑HNS Immunotherapy CPG.

How to choose a provider (checklist)

• Training and certification: Look for ABAI‑certified allergists or relevant ABMS‑certified specialists; confirm experience with your chosen modality. AAAAI “Find an Allergist”.

• Safety infrastructure: Ask about observation protocols (SCIT), first‑dose supervision (SLIT tablets), epinephrine availability, and emergency response drills. AAO‑HNS Immunotherapy CPG.

• Regulatory clarity: For SLIT drops, request written informed consent explaining off‑label status in the U.S. and a plan aligned with practice parameters. ACAAI SLIT overview.

• Fit for your allergens and lifestyle: Tablets cover grass, ragweed, and dust mite; shots (and some drops programs) can address broader inhalant panels. Discuss timing (pre‑season vs year‑round), adherence, and clinic access. AAAAI tablets.

Frequently asked questions

• Which allergens can be treated with FDA‑approved SLIT tablets? Short ragweed, certain grasses (e.g., timothy or mixed northern pasture grasses), and house dust mite. Brand examples include Ragwitek, Grastek/Oralair, and Odactra. AAAAI drug guide.

• Are SLIT drops FDA‑approved in the U.S.? No. SLIT drops for environmental allergens are not FDA‑approved; their use is off‑label. ACAAI, AAAAI.

• Do I need to stay in the office after allergy shots? Yes. Clinics monitor patients in‑office for at least 30 minutes after SCIT, because most severe reactions occur in that window. AAO‑HNS summary of immunotherapy CPG.

• Who should prescribe and supervise immunotherapy? Typically an allergist/immunologist; ENTs also offer immunotherapy in many practices. All prescribers should follow society practice parameters and local regulations. AAAAI parameters index, AAO‑HNS CPG.

• Can telehealth fully replace in‑person visits? Not for procedures. It complements in‑person care for evaluation and follow‑up, but SCIT injections and first SLIT‑tablet doses remain in‑clinic. AAAAI tablets, JACI‑In Practice telehealth review.

Source notes

• Core clinical guidance used here comes from AAAAI/ACAAI Joint Task Force practice parameters and AAO‑HNS clinical practice guidelines, with patient‑facing details on SLIT tablets from AAAAI and ACAAI. See: AAAAI parameters index, AAO‑HNS allergic rhinitis guideline, AAO‑HNS immunotherapy guideline (open‑access summary), AAAAI tablets page, AAAAI drug guide for tablets, and ACAAI SLIT overview.