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Immunotherapy for allergies: drops, tablets, shots, oral immunotherapy and omalizumab

What the trials and labels say about treatments that change the allergy itself, for pollen and dust mite and for food.

4 minute read12 sources, each checked word for wordLibrary checked October 18, 2026

In short

  • Under-the-tongue immunotherapy reduced symptoms and medication use for allergic rhinitis across 49 pooled trials.E1Strong1
  • Three to four years of grass pollen shots led to lasting benefit after treatment stopped.E1Strong2
  • Peanut oral immunotherapy raises the amount people can eat, but it also increases allergic reactions and anaphylaxis compared with avoidance.E1Strong3
  • Omalizumab raised the reaction threshold for peanut and other foods in people as young as 1 year with multiple food allergies.E1Strong4

How sure each claim is:E1StrongE2GoodOfficial textReviewWhat the grades mean

Immunotherapy for pollen and dust mite allergy

Allergen immunotherapy prescribed by a specialist, using high-quality extracts in selected patients, is effective in people with persistent symptoms.Review5

A Cochrane review notes that allergy shots can significantly reduce symptoms and medication use. But their use is limited by the possibility of severe whole-body reactions. That is why the under-the-tongue (sublingual) route drew interest.E1Strong1

That review included 60 randomized trials. Pooled results showed less symptoms and less medication with sublingual immunotherapy than with placebo.E1Strong1

None of the included trials reported severe whole-body reactions or anaphylaxis, and no reaction needed adrenaline.E1Strong1

In a trial of people who had received grass pollen shots for three to four years, the benefit lasted after treatment stopped. There were also lasting changes in immune reactivity.E1Strong2

The FDA-approved tablets

FDA labels for under-the-tongue allergen tablets include these three. Odactra treats house dust mite allergic rhinitis and Grastek treats grass pollen allergic rhinitis. Ragwitek treats short ragweed pollen allergic rhinitis. In each case the allergy is confirmed by skin or blood testing.Official text6,7,8

The Odactra label approves it for people 5 through 65 years of age.Official text6

The Grastek label states it is not for immediate relief of allergy symptoms.Official text7

The Odactra label's boxed warning says the tablets can cause life-threatening allergic reactions such as anaphylaxis and severe throat swelling.Official text6

The Odactra label says the first dose is observed in the office for at least 30 minutes. It also says epinephrine is prescribed with training on its use.Official text6

Oral immunotherapy for peanut

The PALISADE trial studied children and teenagers 4 to 17 years old. At the exit challenge, 67.2% on peanut oral immunotherapy could eat 600 mg or more of peanut protein, against 4.0% on placebo.E1Strong9

Efficacy was not shown in participants 18 or older.E1Strong9

A meta-analysis found high-certainty evidence that peanut oral immunotherapy makes passing a supervised challenge much more likely. It also found high-certainty evidence that it considerably increases allergic reactions and anaphylaxis compared with avoidance or placebo.E1Strong3

The Palforzia label describes it as oral immunotherapy to lessen allergic reactions, including anaphylaxis, from accidental peanut exposure, used with a peanut-avoidant diet. It is not for emergency treatment.Official text10

The label also warns that Palforzia can cause anaphylaxis, reported during all phases of dosing.Official text10

European guidelines recommend oral immunotherapy for children and teenagers with peanut allergy, and suggest it for milk and egg allergy, generally after 4 years of age.E2Good11

Omalizumab (Xolair) for food allergy

In the OUtMATCH trial of people with multiple food allergies, 67% on omalizumab met the trial's main goal for peanut, against 7% on placebo. Results for cashew, milk and egg pointed the same way.E1Strong4

Safety outcomes did not differ between groups, apart from more injection-site reactions with omalizumab.E1Strong4

The Xolair label says it is used to reduce allergic reactions, including anaphylaxis, after accidental exposure to foods. It is for people 1 year and older, together with avoiding the food.Official text12

The label states that Xolair is not for emergency treatment of allergic reactions.Official text12

European guidelines suggest omalizumab for IgE-mediated food allergy in children from age 1 and in adults.E2Good11

What is not known yet

European guidelines suggest sublingual and skin-patch (epicutaneous) immunotherapy for peanut, but note these are not yet available at the point of care.E2Good11

PALISADE did not show benefit in adults with peanut allergy.E1Strong9

Questions you might bring to your clinician

  1. Is this allergy one that immunotherapy is used for, and which route fits: shots, tablets or drops, or oral immunotherapy?
  2. How long would treatment last, and what happens when it stops?
  3. What reactions are possible during treatment, and what is the plan if one happens?
  4. Is omalizumab an option here, and how does it compare with immunotherapy?

Every claim in this guide was written from its sources and checked against them word for word. Its clinical review by Dr. Recio, whose specialty is anesthesia, is pending; an allergist has not yet reviewed it. This line changes when each review is done.

Sources

Each source opens on PubMed, DailyMed or the publisher's page. Under each one are the exact words from it that this page relies on, copied word for word and checked against the original.

  1. Sublingual immunotherapy for allergic rhinitis. Radulovic S, Cochrane Database Syst Rev, 2010. E1Strong Systematic review
    The words this page rests on
    Overall, we found a significant reduction in symptoms (SMD -0.49; 95% confidence interval (CI) -0.64 to -0.34, P < 0.00001) and medication requirements (SMD -0.32; 95% CI -0.43 to -0.21, P < 0.00001) in participants receiving sublingual immunotherapy compared to placebo.
    Immunotherapy by injection can significantly reduce symptoms and medication use but its use is limited by the possibility of severe systemic adverse reactions.
    We included a total of 60 randomised controlled trials in the review.
    None of the trials included in this review reported severe systemic reactions or anaphylaxis, and none of the systemic reactions reported required the use of adrenaline.
  2. Long-term clinical efficacy of grass-pollen immunotherapy. Durham SR, N Engl J Med, 1999. E1Strong Randomized trial
    The words this page rests on
    Immunotherapy for grass-pollen allergy for three to four years induces prolonged clinical remission accompanied by a persistent alteration in immunologic reactivity.
  3. Oral immunotherapy for peanut allergy (PACE): a systematic review and meta-analysis of efficacy and safety. Chu DK, Lancet, 2019. E1Strong Meta-analysis
    The words this page rests on
    In patients with peanut allergy, high-certainty evidence shows that available peanut oral immunotherapy regimens considerably increase allergic and anaphylactic reactions over avoidance or placebo, despite effectively inducing desensitisation.
    Passing a supervised challenge, a surrogate for preventing out-of-clinic reactions, was more likely with oral immunotherapy (RR 12·42 [95% CI 6·82-22·61], I2=0%, RD 36·5%, high-certainty).
  4. Omalizumab for the Treatment of Multiple Food Allergies. Wood RA, N Engl J Med, 2024. E1Strong Randomized trial
    The words this page rests on
    In persons as young as 1 year of age with multiple food allergies, omalizumab treatment for 16 weeks was superior to placebo in increasing the reaction threshold for peanut and other common food allergens.
    A total of 79 of the 118 participants (67%) receiving omalizumab met the primary end-point criteria, as compared with 4 of the 59 participants (7%) receiving placebo (P<0.001).
    Results for the key secondary end points were consistent with those of the primary end point (cashew, 41% vs. 3%; milk, 66% vs. 10%; egg, 67% vs. 0%; P<0.001 for all comparisons). Safety end points did not differ between the groups, aside from more injection-site reactions in the omalizumab group.
  5. Allergic rhinitis. Bousquet J, Nat Rev Dis Primers, 2020. Review Expert review
    The words this page rests on
    Allergen immunotherapy prescribed by a specialist using high-quality extracts in stratified patients is effective in patients with persistent symptoms.
  6. ODACTRA (house dust mite allergen extract) sublingual tablet, Prescribing Information. ALK-Abello A/S, 2026. Official text FDA label
    The words this page rests on
    ODACTRA is an allergen extract indicated as immunotherapy for the treatment of house dust mite (HDM)-induced allergic rhinitis, with or without conjunctivitis
    ODACTRA is approved for use in individuals 5 through 65 years of age.
    ODACTRA can cause life-threatening allergic reactions such as anaphylaxis and severe laryngopharyngeal restriction.
    Observe patients in the office for at least 30 minutes following the initial dose.
    Prescribe epinephrine, instruct and train patients or parents/guardians on its appropriate use, and instruct patients or parents/guardians to seek immediate medical care upon its use.
  7. GRASTEK (Timothy grass pollen allergen extract) sublingual tablet, Prescribing Information. ALK-Abello A/S, 2022. Official text FDA label
    The words this page rests on
    GRASTEK is an allergen extract indicated as immunotherapy for the treatment of grass pollen-induced allergic rhinitis with or without conjunctivitis confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies for Timothy grass or cross-reactive grass pollens.
    GRASTEK is not indicated for the immediate relief of allergic symptoms.
  8. RAGWITEK (short ragweed pollen allergen extract) sublingual tablet, Prescribing Information. ALK-Abello A/S, 2022. Official text FDA label
    The words this page rests on
    RAGWITEK is an allergen extract indicated as immunotherapy for the treatment of short ragweed pollen-induced allergic rhinitis, with or without conjunctivitis, confirmed by positive skin test or in vitro testing for pollen-specific IgE antibodies for short ragweed pollen.
  9. AR101 Oral Immunotherapy for Peanut Allergy. PALISADE Group of Clinical Investigators, N Engl J Med, 2018. E1Strong Randomized trial
    The words this page rests on
    Of the 551 participants who received AR101 or placebo, 496 were 4 to 17 years of age; of these, 250 of 372 participants (67.2%) who received active treatment, as compared with 5 of 124 participants (4.0%) who received placebo, were able to ingest a dose of 600 mg or more of peanut protein, without dose-limiting symptoms, at the exit food challenge (difference, 63.2 percentage points; 95% confidence interval, 53.0 to 73.3; P<0.001).
    Efficacy was not shown in the participants 18 years of age or older.
  10. PALFORZIA [Peanut (Arachis hypogaea) Allergen Powder-dnfp], Package Insert. Aimmune Therapeutics, Inc., 2024. Official text FDA label
    The words this page rests on
    PALFORZIA is an oral immunotherapy indicated for the mitigation of allergic reactions, including anaphylaxis, that may occur with accidental exposure to peanut. PALFORZIA is approved for use in patients with a confirmed diagnosis of peanut allergy. Initial Dose Escalation may be administered to patients aged 1 through 17 years.
    PALFORZIA is to be used in conjunction with a peanut-avoidant diet. Limitation of Use: Not indicated for the emergency treatment of allergic reactions, including anaphylaxis.
    PALFORZIA can cause anaphylaxis, which may be life-threatening. Anaphylaxis has been reported during all phases of PALFORZIA dosing, including Maintenance and in subjects who have undergone recommended Up-Dosing and dose modification procedures.
  11. EAACI guidelines on the management of IgE-mediated food allergy. Santos AF, Allergy, 2025. E2Good Guideline
    The words this page rests on
    As immunomodulatory interventions, omalizumab is suggested for treatment of IgE-mediated food allergy in children from the age of 1 and adults; and oral allergen-specific immunotherapy is recommended for children and adolescents with peanut allergy and suggested for milk and egg allergies (generally after 4 years of age for milk and egg).
    Sublingual and epicutaneous immunotherapy are suggested for peanut allergy but are not yet available at the point of care.
  12. XOLAIR (omalizumab) injection, Prescribing Information. Genentech, Inc., 2026. Official text FDA label
    The words this page rests on
    XOLAIR is indicated for the reduction of allergic reactions (Type I), including anaphylaxis, that may occur with accidental exposure to one or more foods in adult and pediatric patients aged 1 year and older with IgE-mediated food allergy. XOLAIR is to be used in conjunction with food allergen avoidance.
    XOLAIR should not be used for the emergency treatment of allergic reactions, including anaphylaxis.