Procedure Guide: Subcutaneous Immunotherapy

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology

Allergen immunotherapy was introduced by Leonard Noon 100 years ago and is the only disease-modifying treatment for allergic individuals (Allergy, 2012). The type of extracts used for subcutaneous immunotherapy depends on the reactivity to a particular allergen on the skin prick testing.


Diagram of skin prick testing


Skin test sheet. Image source: Dr. Stokes, Creighton University Division of Allergy & Immunology, used with permission.

The skin prick allergens are listed on the sheet in the order they appear in the environment during the year and can be remembered with the mnemonic:

How the allergens change during the season: mnemonic TGR MI DC/DC ("a Tiger with an MI went to DC")

"There's spring time, where you have the tree pollen. Summer time, where you have the grass pollens. And then there's the fall time when you have the weed pollen.”

This sequence is remembered by the mnemonic TGR MI DC/DC ("a Tiger with an MI went to DC").

Pollen calendar: TGR MI DC/DC

Tree pollens
Grass pollens
Ragweed and weed pollen

Mold spores
Indoor allergens - DC/DC - Dog/Cat and Dust mite/Cockroach


Pollen-producing plants (weeds and trees) in Omaha, Nebraska

References:

Characteristics of allergic sensitization among asthmatic adults older than 55 years: results from the National Health Allergy Season Year Round. WTOC-TV Savannah.
Interactive Allergy Map by Greer Labs. Click your state to find region-specific, common airborne allergens there.
‘Botanical sexism’ blamed for making life miserable for allergy sufferers as male trees fill city skies with pollen http://goo.gl/cx5tH


Immunotherapy Preparation. Image source: Dr. Stokes, Creighton University Division of Allergy & Immunology, used with permission.

Molds include AAHP (Alternaria, Aspergillus, Hormodendrum, Penicillium) and Minor Mold Mix.

Many patients require 2 vials of extracts. Each vial contains 10 ml of extract solution. If the total amount of allergen extract is less than 10 ml, the rest of vial is filled with diluent to a total of 10 ml.

Animal extracts (cat, dog) are not mixed with "other animals" such as cockroach, mite, molds. Molds include AAHP (Alternaria, Aspergillus, Hormodendrum, Penicillium) and Minor Mold Mix.


Immunotherapy order sheet. Image source: Dr. Stokes, Creighton University Division of Allergy & Immunology, used with permission.

Mixing allergen extracts with high protease content

Mnemonic

M
Mold
Mite - cockroach has even more proteases than mite
Mixing problems - proteases degarade grass extracts in particular and decrease their potency

Sublingual immunotherapy

Sublingual immunotherapy induces similar immunologic alterations as subcutaneous immunotherapy, although to a lesser degree.

Omalizumab

The combination of omalizumab with allergen subcutaneous immunotherapy can enhance clinical efficacy.

Oral Immunotherapy

Sublingual immunotherapy induces similar immunologic alterations as subcutaneous immunotherapy, although to a lesser degree.

Currently the only product approved for clinical use by European regulators is a tablet containing timothy grass extract. There are no products approved for oral immunotherapy in the US.

Optimal duration of sublingual therapy is not defined. The NEJM published a review of SLIT in 2008.

What are the 4 standardized allergen extracts?

(A) Dog
(B) Trees
(C) Cat
(D) Molds
(E) Dust Mite
(F) Grass
(G) Ragweed

The 4 standardized extracts are Cat, Dust Mite, Grass and Ragweed.

References

Allergen immunotherapy: A practice parameter second update. JACI, 2007 (PDF).
Allergen Immunotherapy. AFP, 2004.
Allergy Immunotherapy for Primary Care Physicians. J . Stokes , T . Casale. The American Journal of Medicine , Volume 119 , Issue 10 , Pages 820 - 823 (2006). Link via MDConsult.
Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility. ACAAI.
Allergen injection immunotherapy. John M Weiner. MJA 2006; 185 (4): 234.
Use of Immunotherapy in a Primary Care Office. AFP, 1998.
Advances in upper airway diseases and allergen immunotherapy in 2007. Saltoun C, Avila PC. J Allergy Clin Immunol. 2008 Aug 9.
Sublingual Immunotherapy. Anthony J. Frew. NEJM, Volume 358:2259-2264, May 22, 2008.
Allergen-Specific Immunotherapy of Allergy and Asthma: Current and Future Trends. Fran├žois Spertini; Christophe Reymond; Annette Leimgruber. Expert Review of Respiratory Medicine, Medscape, 03/2009.

Video

Immunotherapy Rx, Part 1 and 2, Jay Portnoy, MD. Conferences Online For Allergy, Children's Mercy Hospitals & Clinics, 2009.
Immunotherapy. Linda Cox, MD. Conferences Online For Allergy, Children's Mercy Hospitals & Clinics, Feb 4, 2009.
Allergy shots by Dr. Y. Patel.

Patient Information

What is immunotherapy and how does it work? AAAAI, 2006.

Published: 07/03/2008
Updated: 08/15/2010

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