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

S44 Cox et al
J ALLERGY CLIN IMMUNOL
SEPTEMBER 2007
Five patients experienced more than 3 systemic reactions
(total of 36 reactions), and the authors noted that 40% of
the systemic reactions (21 reactions) would have been
avoided if patients experiencing the third systemic reaction
had been withdrawn.
In the previously mentioned AAAAI physician members’
survey of fatal reactions and NFRs, there were 41
fatalities identified in the initial brief survey (20 directly
reported and 17 with completed detailed questionnaire)
from immunotherapy injections. 188 The estimated fatality
rate was 1 per 2.5 million injections, (average of 3.4 deaths
per year), which is similar to 2 previous surveys of AAAAI
physician members. 189,190 Therefore although severe systemic
reactions to allergen immunotherapy are not common,
serious systemic reactions (some fatal) can occur.
Summary Statement 15: An assessment of the patient’s
current health status should be made before administration
of the allergy immunotherapy injection to determine
whether there were any recent health changes that might
require modifying or withholding that patient’s immunotherapy
treatment. Risk factors for severe immunotherapy
reactions include symptomatic asthma and injections
administered during periods of symptom exacerbation.
Before the administration of the allergy injection, the
patient should be evaluated for the presence of asthma or
allergy symptom exacerbation. One might also consider
an objective measure of airway function (eg, peak flow)
for the asthmatic patient before allergy injections. B
In the AAAAI survey of physician members on immunotherapy
and skin testing, fatal reactions, and NFRs
during the period of 1990-2001, 15 of the 17 fatalities had
asthma, and in 9 patients asthma was considered the
susceptibility factor that contributed to the fatal
outcome. 188
The most severe NFR, respiratory failure, occurred
exclusively in asthmatic patients, and 4 (57%) of 7
asthmatic patients had a baseline FEV 1 of less than 70%
of predicted value. 184
Administration during the peak pollen season (3 patients)
and previous systemic reactions (4 patients) were
cited as other contributing factors. Five fatalities occurred
in outside medical facilities, and 2 fatalities occurred at
home. No patients were receiving b-blockers; 1 patient
was taking an angiotensin-converting enzyme inhibitor. In
the most comprehensive evaluation of fatalities associated
with allergen immunotherapy, from 1945-1987, there
were 40 fatalities during allergen immunotherapy and 6
fatalities during skin testing. 189 Ten fatalities occurred
during seasonal exacerbation of the patient’s disease, 4
in patients who had been symptomatic at the time of the
injection, 2 of whom had been receiving b-adrenergic
blockers. Of the 24 fatalities associated with immunotherapy,
4 had experienced previous reactions, 11 manifested
a high degree of sensitivity, and 4 had been injected with
newly prepared extracts. In a prospective study of 125
asthmatic patients with mite allergy that used a 3-day
rush immunotherapy protocol, FEV 1 was identified as a
predictor for systemic reactions, with 73.3% of patients
with an FEV 1 of less than 80% of predicted value
experiencing an asthma reaction during rush immunotherapy,
whereas only 12.6% of patients with an FEV 1 of
greater than 80% of predicted value had asthmatic reactions
(P