Clinical process for properly prescribe allergen immunotherapy

Noel Rodriguez-Perez, MDProfessor of pediatrics, Allergy& Immunology

State University of Tamaulipas, School of Medicine

Cox L, Nelson HS, Lockey RF. Journal of Allergen immunotherapy: A practice parameter third update Allergy Clin Immunol

2011;127:S1-S46

Summary Statement 80: The efficacy of immunotherapy depends on achieving an optimal therapeutic dose of each of the constituents in the allergen immunotherapy extract. A

Clinical process for properly prescribe allergen immunotherapy

Allergen immunotherapy: What can and cannot be mixed?

Esch RE. J Allergy Clin Immunol 2008;122:659-60.

CASE 1: M.D.K. Male. 16 years of age

Previous history: Cow’s milk allergy in

infancy.

Hystory: 2 years, recurrent episodes of

coriza, nasal congestion, acuous rhinorrea,

epifora, fotofobia, intermitent dry cough.

Symptoms, perenial with exacerbations in

Winter, Spring and summer.

Clinical process for properly prescribe allergen immunotherapy

Skin test. Case 1 M.D.K

Case 1: M.D.K.

1. What allergens to be included?2. How many in one vial?3. Can we mix this unrelated allergens?

Zuberbier T, Bachert C, Bousquet PJ, Passalacqua G, Walter Canonica G, Merk H, Worm M, Wahn U, Bousquet J. GA2LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma. Allergy 2010; 65:

1525–1530.

Decision must be based on the allergen which causes:

1. The longest duration of symptoms per year

2. The most severe symptoms

3. A major impact on quality of life

4. Which is more difficult to avoid

House dust mites…Related to perennial symptoms

Tree pollens… Late winter to early Spring

Grass pollens…Late Spring to early Summer

Weed pollens…Summer to early Autumn

CASE 1: M.D.K.

CASE 1: M.D.K. Pollen SIT

Quercus, Celtis, Sorgum, Ambrosia, Rumex

Pollens probably effective dose range: 5 – 20 mcg

(1:100 – 1:200 w/v)

5 pollen mix will dilute each other times 5.

Maintenance dose Vial: 1:200 V1 X C1 = V2 X C2 Were:

V1 = Final volume to prepare

C1 = Desired concentration of extract

V2 = Volume of extract needed (unknown)

C2 = Concentration of extract you will use (manufacturer

concentrate)JACI. 2011;127:S1-S46

CASE 1: M.D.K. Pollen SIT

Pollen maintenance vial.Option: 5cc 1:200 w/v V2 = (V1/ C1)xC2

V2 (?) = (5cc / 1/200)x1:20 w/v = (5/200)x20 = 0.5

V2 = 0.5cc of each pollen extract

Mix of 5 pollen extracts: 0.5x5 = 2.5cc + 2.5cc of

diluent.

Option: 1:100

V2 = (5/100)x20 = 1cc

Mix of 5 pollen extracts: 5cc no diluent.

CASE 1: M.D.K: H.D.Mites or standarized

Immunotherapy

Mites maintenance vial F/Pt mix 50/50.Manufacturer concentrate: 10,000; 30,000 AU/mL

Effective maintenance dose: 500 – 2000 AU or

10mcg/mL (Mf: 10mcg; MPt: 7 – 12 mcg/mL)

Maintenance vial: 2000 AU/mL.

V2 = (V1 x C1)/C2

V2 (?) = (5cc x 2000)/10,000 AU = 1.0cc

V2 = 1.0cc + 4cc Diluent ( 12mcg/mL; 6

mcg/dose)

Major allergen component in standarized extracts

ExtractConcentratio

nMajor

componentContent

Effective dose/projecte

d dose

Poa annua 100k BAU/mL Group 5 320 μg/mL 5 to 20µg/ 1000 to 4000AU

Agropiron rep 100k BAU/mL Group 5750 μg/mL

5 to 20µg/ 1000 to 4000AU

Phleum Prat 100k BAU/mL Phl p5 680 μg/mL 20µg/

1000 to 4000AU

Cynodon dact 10k BAU/mL Group 1 300 μg/mL5 to 20µg/

1000 to 4000AU

Ambrosia 1:10 w/v Amb a 1290 μg/mL 6 to 12µg

1000 to 4000AU

D farinae 10k BAU/mL Group 1 60 μg/mL 10 μg

D pteronisinus 10k BAU/mL Group 1 65 μg/mL 7 a 12 μg

Cat 10k BAU/mL Fel d 1 50 μg/mL 15 μg

Dose of Major component in mcg/mL

Suppose 5cc maintenance dose vial for 10 doses of 0.5cc with Timothy grass pollen.5cc must contain 10 times the maintenance dose.

Example: Timothy grass maintenance effective dose 20mcg/mL Phl p5. 5 cc maintenance vial must contain 200mcg.Manufacturer label 100000AU/mL = 680mcg of Phl p5/mL.200 divided by 680 = 0.3cc + 4.7cc of diluent.