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

S64 Cox et al
J ALLERGY CLIN IMMUNOL
SEPTEMBER 2007
with allergic rhinitis, allergic rhinoconjunctivitis, allergic
asthma, and stinging insect hypersensitivity. It might
prevent the new onset of allergen sensitivities or progression
to asthma. A
Immunotherapy for children has been shown to be effective
and often well tolerated, 137,242 although at least one
study did not show efficacy. 293 However, this study did
not include an important allergen, cockroach, which has
been shown to correlate with asthma severity in other studies
of inner-city asthmatic children. 294 In general, the clinical
indications for immunotherapy for allergic rhinitis and
asthma are similar for adults and children (see the Patient
selection section and Table VII). In recent studies children
receiving allergen immunotherapy have demonstrated:
1. improvement in symptom control for
asthma 117,119,121,122 and allergic rhinitis 118 ;
2. increased PC 20 to histamine 121 ;
3. increased PC 20 to cat and house dust mite
allergens 121,149 ;
4. decreased risk of development of asthma 6,9,163-165 ;
5. decreased development of new sensitivities 120,166 ; and
6. modification in release of mediators in children receiving
immunotherapy that correlates with decreased
clinical symptoms. 123
Summary Statement 70: Children under 5 years of
age can have difficulty cooperating with an immunotherapy
program. Therefore the physician who evaluates
the patient must consider the benefits and risks of immunotherapy
and individualize treatment in patients under
the age of 5 years. A
Although there is some disagreement about the role of
allergen immunotherapy in children under the age of 5
years, there have been reports of effectiveness of allergen
immunotherapy in this age group. 117,122 In children with
allergic rhinitis, allergen immunotherapy might prevent
the development of asthma. 6,9,163-165 However, allergen
immunotherapy for inhalant allergens is usually not considered
necessary in infants and toddlers because (1) there
is difficulty in communicating with the child regarding
systemic reactions, and (2) injections can be traumatic to
very young children. Therefore each case should be considered
individually by weighing the benefits and risks.
For children who have had a history of anaphylaxis to
stinging insects or have severe allergic disease, the benefits
of allergen immunotherapy might outweigh the risks.
Immunotherapy in pregnancy
Summary Statement 71: Allergen immunotherapy
might be continued but is usually not initiated in the
pregnant patient. C
The physician must be aware of the benefits and risks of
immunotherapy in pregnant patients. The recommended
precautions for prevention of adverse reactions are especially
important in the pregnant patient. Allergen immunotherapy
is effective in the pregnant patient. Thus allergen
immunotherapy maintenance doses can be continued
during pregnancy. Allergen immunotherapy is usually not
initiated during pregnancy because of risks associated with
systemic reactions and their treatment (ie, spontaneous
abortion, premature labor, or fetal hypoxia). The initiation
of immunotherapy might be considered during pregnancy
when the clinical indication for immunotherapy is a highrisk
medical condition, such as anaphylaxis caused by
Hymenoptera hypersensitivity. When a patient receiving
immunotherapy reports that she is pregnant, the dose of
immunotherapy is usually not increased, and the patient is
maintained on the dose that she is receiving at that time.
Immunotherapy in the elderly patient
Summary Statement 72: Comorbid medical conditions
and certain medication use might increase the risk from
immunotherapy in elderly patients. Therefore special
consideration must be given to the benefits and risks of
immunotherapy in this patient population. D
Immunotherapy might be considered in the treatment of
the elderly patient, but the benefit/risk assessment must be
evaluated carefully in this population. Older patients
might be taking medications that could make treatment
of anaphylaxis with epinephrine more difficult, such as
b-blockers, or might have significant comorbid medical
conditions, such as hypertension, coronary artery disease,
cerebrovascular disease, and/or cardiac arrhythmias.
However, elderly patients may also benefit from allergen
immunotherapy and age alone should not preclude the
consideration of allergen immunotherapy. 295
Immunotherapy in patients with
immunodeficiency and autoimmune
disorders
Summary Statement 73: Immunotherapy can be considered
in patients with immunodeficiency and autoimmune
disorders. D
There are no controlled studies about the effectiveness
or risks associated with immunotherapy in patients with
immunodeficiency or autoimmune disorders. Therefore
the decision to begin immunotherapy in patients with
major humoral or cellular immune defects must be individualized.
Concern about the increased risk of immunotherapy
in such patients is largely hypothetical.
Although concern about the safety of allergen immunotherapy
in patients with autoimmune disease or connective
tissue disease has been raised in the past, there is
no substantive evidence that such treatment is harmful in
these diseases. Therefore the benefits and risks of allergen
immunotherapy in patients with autoimmune or connective
tissue must be assessed on an individual basis.
ALTERNATIVE ROUTES OF
IMMUNOTHERAPY
Sublingual and oral immunotherapy
Summary Statement 74: Optimal high-dose sublingual
swallow and oral immunotherapies are under clinical
investigation in the United States. Studies of oral immunotherapy
have demonstrated conflicting results. Highdose
sublingual immunotherapy has been found to be