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

S60 Cox et al
J ALLERGY CLIN IMMUNOL
SEPTEMBER 2007
allergen (eg, pollen or molds), (3) continued exposure to
nonallergen triggers (eg, tobacco smoke), or (4) incomplete
identification and treatment of clinically relevant allergens.
If clinical improvement is not apparent after
1 year of maintenance therapy, possible reasons for lack
of efficacy should be evaluated. If none are found, discontinuation
of immunotherapy should be considered, and
other treatment options should be pursued.
Follow-up visits. Summary Statement 54: Patients
should be evaluated at least every 6 to 12 months while
they receive immunotherapy. D
Patients should be evaluated at least every 6 to 12
months while receiving immunotherapy:
d to assess efficacy;
d to implement and reinforce its safe administration and
to monitor adverse reactions;
d to assess the patient’s compliance with treatment
d to determine whether immunotherapy can be discontinued;
and
d to determine whether adjustments in immunotherapy
dosing schedule or allergen content are necessary.
Patients might need more frequent office visits for
evaluation and management of immunotherapy (eg, treatment
of local reactions, systemic reactions, or both or
changes in their immunotherapy vials or lots) or changes
in the management of underlying allergic disease or
comorbid conditions.
Duration of treatment
Summary Statement 55a: At present, there are no
specific tests or clinical markers that will distinguish
between patients who will relapse and those who will
remain in long-term clinical remission after discontinuing
effective inhalant allergen immunotherapy, and the duration
of treatment should be determined by the physician
and patient after considering the benefits and risks associated
with discontinuing or continuing immunotherapy. D
Summary Statement 55b: Although there are no specific
tests to distinguish which patients will relapse after
discontinuing VIT, there are clinical features that are
associated with a higher chance of relapse, notably a history
of very severe reaction to a sting, a systemic reaction during
VIT (to a sting or a venom injection), honeybee venom
allergy, and treatment duration of less than 5 years. C
Summary Statement 55c: The patient’s response to
immunotherapy should be evaluated on a regular basis. A
decision about continuation of effective immunotherapy
should generally be made after the initial period of up to
5 years of treatment. D
Summary Statement 55d: The severity of disease,
benefits sustained from treatment, and convenience of
treatment are all factors that should be considered in
determining whether to continue or stop immunotherapy
for any individual patient. D
Summary Statement 55e: Some patients might experience
sustained clinical remission of their allergic disease
after discontinuing immunotherapy, but others might
relapse. B
The patient’s response to immunotherapy should be
evaluated on a regular basis. The severity of disease,
benefits sustained from treatment, and convenience of
treatment are all factors that should be considered in
determining whether to continue or stop immunotherapy
for any individual patient. If allergen immunotherapy is
effective, treatment might be continued for longer than
3 years, depending on the patient’s ongoing response
to treatment. Some patients experience a prolonged
remission after discontinuation, but others might relapse
after discontinuation of immunotherapy. Therefore the
decision to continue or stop immunotherapy must be
individualized.
There have been very few studies designed specifically
to look at the question of when to discontinue effective
allergen immunotherapy or the duration of immunotherapy
efficacy after termination of treatment. The duration of
allergen immunotherapy efficacy has probably been most
extensively studied in Hymenoptera hypersensitivity.
Long-term follow-up studies suggest that a 5-year
immunotherapy treatment course for Hymenoptera hypersensitivity
might be sufficient for most allergic individuals.
283-285 However, relapse rates as high as 15% of
patients in the 10-year period after discontinuing VIT
have been reported. 283,285 Nevertheless, systemic reactions
to stings after discontinuing VIT were generally
much milder than the pretreatment reactions and were
rarely severe. Two studies did not find a difference in relapse
rates between the patients treated for 3 years compared
with those treated for 5 years, 283,286 but one of the
studies noted that the small number of patients in the 3-
year treatment group prevented them from making any
conclusions about the risk of discontinuing treatment after
3 years. 283 However, one study found that patients
who had experienced re-sting reactions after discontinuing
VIT had received VIT for a significantly shorter
duration (mean, 43.35 months) than those with continued
protection (mean, 54.65 months; P