Immunotherapy Safety for the Primary Care ... - U.S. Coast Guard

J ALLERGY CLIN IMMUNOL
VOLUME 120, NUMBER 3
Cox et al S27
Stephen Durham, MD, London, UK
Ira Finegold, MD, New York, NY
Stephen Kemp, Jackson, Miss
Brian Smart, MD, Glen Ellyn, Ill
Mark L. Vandewalker, MD, Columbia, Mo
Richard Weber, MD, Denver, Colo
David Weldon, MD, College Station, Tex
REVIEWERS OF ALLERGEN EXTRACT
SECTION
Robert Esch, PhD, Lenoir, NC
Larry Garner, CPT, BA, Spokane, Wash
Richard Lankow, PhD, Round Rock, Tex
Greg Plunkett, PhD, Round Rock, Tex
Tom Willoughby, Liberty, Miss
The authors and editors gratefully acknowledge Susan
Grupe for her administrative assistance.
Allergen immunotherapy: A practice parameter
second update
Preface
S27
Algorithm and annotations for immunotherapy S28
Immunotherapy glossary
S31
Introduction
S33
Summary statements
S33
Mechanisms of immunotherapy
S38
Allergen extracts
S38
Efficacy of immunotherapy
S41
Safety of immunotherapy
S43
Patient selection
S46
Allergen selection and handling
S48
Immunotherapy schedules and doses
S53
Location of allergen immunotherapy
administration
S61
Special considerations in immunotherapy S63
Alternative routes of immunotherapy S64
Future trends in immunotherapy
S66
References
S67
PREFACE
This document was developed by the Joint Task Force
on Practice Parameters, which represents the American
Academy of Allergy, Asthma and Immunology (AAAAI);
the American College of Allergy, Asthma and Immunology
(ACAAI); and the Joint Council of Allergy, Asthma
and Immunology (JCAAI).
The objective of ‘‘Allergen immunotherapy: A practice
parameter second update’’ is to optimize the practice of
allergen immunotherapy for patients with allergic rhinitis,
allergic asthma, and Hymenoptera sensitivity. This parameter
is intended to establish guidelines for the safe and
effective use of allergen immunotherapy, while reducing
unnecessary variation in immunotherapy practice. These
guidelines have undergone an extensive peer-review
process consistent with recommendations of the
American College of Medical Quality’s ‘‘Policy on development
and use of practice parameters for medical
quality decision-making’’ (Appendix 1). 1
This document builds on the previous Joint Task Force
document, ‘‘Allergen immunotherapy: a practice parameter’’
published in the Annals of Allergy, Asthma and
Immunology in 2003. 2 The updated practice parameters
draft was prepared by Drs Linda Cox, James Li, Hal
Nelson, and Richard Lockey. The Joint Task Force
reworked the initial draft into a working draft of the
document. The project was exclusively funded by the 3
allergy and immunology societies noted above.
In preparation for the 2003 ‘‘Allergen immunotherapy:
a practice parameter’’ and the second update, a comprehensive
search of the medical literature was conducted with
various search engines, including PubMed; immunotherapy,
allergic rhinitis, asthma, stinging insect allergy, and
related search terms were used. Published clinical studies
were rated by category of evidence and used to establish
the strength of a clinical recommendation (Table I). 3
Laboratory-based studies were not rated.
The working draft of ‘‘Allergen immunotherapy: a
practice parameter second update’’ was reviewed by a
large number of experts in immunotherapy, allergy, and
immunology. These experts included reviewers appointed
by the ACAAI, AAAAI, and JCAAI. In addition, the draft
was posted on the ACAAI and AAAAI Web sites with an
invitation for review and comments from members of the
sponsoring organizations. The authors carefully considered
all of these comments in preparing the final version.
An annotated algorithm in this document summarizes the
key decision points for the appropriate use of allergen
immunotherapy (Fig 1).
The section on efficacy summarizes the evidence
demonstrating that allergen immunotherapy is effective in
the management of properly selected patients with allergic
rhinitis, allergic asthma, and stinging insect hypersensitivity.
This document also contains recommendations for
the safe practice of allergen immunotherapy, including
specific recommendations on the prevention and management
of systemic reactions.
Specific recommendations guide the physician in
selecting those patients for whom allergen immunotherapy
is appropriate. Aeroallergen immunotherapy should be
considered for patients who have symptoms of allergic
rhinitis or asthma with natural exposure to allergens and
who demonstrate specific IgE antibodies to the relevant
allergen or allergens. Symptoms of allergic conjunctivitis
(eg, itchy watery eyes) are often considered part of allergic
rhinitis or are included in the diagnosis of rhinoconjunctivitis.
Particularly good candidates for immunotherapy are
patients whose symptoms are not controlled adequately by
medications and avoidance measures, those in whom it is
important to avoid the potential adverse effects of medications,
and those who wish to reduce the long-term use of
medications. Immunotherapy is recommended for patients
with a history of systemic reaction to Hymenoptera stings
and specific IgE antibodies to Hymenoptera venom.