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.
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. François 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.
Patient Information
What is immunotherapy and how does it work? AAAAI, 2006.
Published: 07/03/2008
Updated: 08/15/2010
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. François 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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