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

S46 Cox et al
J ALLERGY CLIN IMMUNOL
SEPTEMBER 2007
TABLE V. Actions to reduce the risk of anaphylaxis
d
d
d
d
d
d
d
d
Assess the patient’s general medical condition at the time of injection (eg, asthma exacerbation).
Consider obtaining a PEFR before administration of the injection. If the PEFR is significantly less than the patient’s baseline value, the
clinical condition of the patient should be evaluated before administration of the injection.
Adjust the immunotherapy dose or injection frequency if symptoms of anaphylaxis occur and immunotherapy is continued.
Use appropriately diluted initial allergen immunotherapy extract in patients who appear to have increased sensitivity on the basis of history
or tests for specific IgE antibodies.
Instruct patients to wait in the physician’s office/medical facility for 30 minutes after an immunotherapy injection. Patients at greater risk
of reaction from allergen immunotherapy (eg, patients with increased allergen sensitivity or those who have previously had a systemic
reaction) might need to wait longer.
Carefully evaluate any patient with a late reaction (eg, persistent large local reaction lasting >24 hours, systemic reaction occurring more
than 30 minutes after the immunotherapy injection).
Ensure procedures to avoid clerical or nursing errors (eg, careful checking of patient identification).
Recognize that dosage adjustments downward are usually necessary with a newly prepared allergen immunotherapy extract or a patient who
has had a significant interruption in the immunotherapy schedule.
PEFR, Peak expiratory flow rate measurement.
TABLE VI. Recommended equipment and medications to treat anaphylaxis
Adequate equipment and medications should be immediately available to treat anaphylaxis, should it occur. This should include at least the
following equipment and medications:
d stethoscope and sphygmomanometer;
d tourniquet, syringes, hypodermic needles, and large-bore needles (14-gauge);
d aqueous epinephrine HCL 1:1000 wt/vol;
d equipment to administer oxygen by mask.
d intravenous fluid set-up;
d antihistamine for injection (second-line agents for anaphylaxis, but H 1 and H 2 antihistamines work better together than either one alone);
d corticosteroids for intravenous injection;
d vasopressor;
d equipment to maintain an airway appropriate for the supervising physician’s expertise and skill.
for allergen immunotherapy. Examples include severe
asthma uncontrolled by pharmacotherapy and significant
cardiovascular disease. C
Alternatives to allergen immunotherapy should be
considered in patients with any medical condition that
reduces the patient’s ability to survive a systemic allergic
reaction. Examples include patients with markedly compromised
lung function (either chronic or acute), poorly
controlled asthma, unstable angina, recent myocardial
infarction, significant arrhythmia, and uncontrolled hypertension.
Under some circumstances, immunotherapy
might be indicated for high-risk patients, such as those
with Hymenoptera venom hypersensitivity and cardiac
disease being treated with b-blocker medications.
Reducing the risk of anaphylaxis to
immunotherapy injections
Summary Statement 19: Allergen immunotherapy
should be administered in a setting where procedures
that can reduce the risk of anaphylaxis are in place and
where the prompt recognition and treatment of anaphylaxis
is ensured. C
The major risk of allergen immunotherapy is anaphylaxis,
which in extremely rare cases can be fatal, despite
optimal management. Therefore allergen immunotherapy
should be administered in a setting where anaphylaxis will
be promptly recognized and treated by a physician or other
health care professional appropriately trained in emergency
treatment.
The health care professional who administers immunotherapy
injections should be able to recognize and treat
the early symptoms and signs of anaphylaxis and administer
emergency treatment, if necessary. Epinephrine is the
first-line treatment for anaphylaxis. Health care professionals
should know the potential pharmacologic benefits,
risks, and routes of administration of epinephrine, as well
as the potential reasons for lack of response. 12,207-213 It is
important to administer epinephrine early in the management
of anaphylaxis. Appropriate personnel, equipment,
and medications should be immediately available to treat
anaphylaxis, should it occur. Suggested actions to reduce
the risk of anaphylaxis and recommended equipment and
medications to treat anaphylaxis are listed in Tables V and
VI, respectively. Before allergen immunotherapy is chosen
as a treatment, the physician should educate the patient
about the benefits and risks of immunotherapy, as well as
methods for minimizing risks. The patient also should be
told that despite appropriate precautions, reactions might
occur without warning signs or symptoms. Informed consent
should include a discussion of the potential immunotherapy
adverse reactions, and this discussion should be
documented in the patient’s medical record.
PATIENT SELECTION
Clinical indications
Summary Statement 20: Allergen immunotherapy
should be considered for patients who have demonstrable