Allergen injection treatment, also known as allergen immunotherapy, is an effective form of treatment for patients allergic to house dust, dust mites, mold spores, pollens, and stinging insects. By giving increasing doses of the allergens to which one is allergic via subcutaneous injections, "blocking antibodies" can be produced that protect an individual by diminishing one's response to subsequent exposure to the allergens. In this way, allergen immunotherapy modifies the allergic state by reducing its severity. In most patients, the reduction of severity of symptoms will be marked, while in others moderate.

Immunotherapy is frequently recommended for long-term control of allergic rhinitis (hay fever) and allergic asthma for the following reasons:

1. It is the only type of treatment available that can act body's response to the airborne allergens. Immunotherapy may produce a long-term reduction in your allergic sensitivity. Other medications simply treat your symptoms without changing your allergic sensitivity.

2. If you are allergic to unavoidable pollens, it is very unlikely that you will never be significantly better without immunotherapy. Your symptoms may vary in severity depending on the amount of allergen to which you are exposed, but every year you will be exposed to these allergens and will have some symptoms.

3. Injection therapy is remarkably effective. Approximately 90% of all allergic people treated this way get markedly better.

Effectiveness of allergen immunotherapy is maximized only when given in conjunction with environmental control of avoidable allergens such as house dust, molds, and animal dander. Failure to maintain adequate avoidance measures for these household allergens can lead to disappointing results from immunotherapy.

IF THE DOCTOR RECOMMENDS IMMUNOTHERAPY, WHAT TO EXPECT:

If the doctor recommends immunotherapy for you, this treatment can be started one week after completion of your allergy work-up. Our office will make up a concentrated vial of allergy extract specifically for you containing those allergens to which you are allergic. We will then make a series of four diluted vials from this concentrated vial. Your treatment will start with the most diluted vial and over the next few months you will progress to the higher concentration vials until you reach the original concentrated vial or you are unable to tolerate further increases in your dose. The highest dose you can obtain is called your Maintenance Dose.

The frequency of injections varies with your stage of treatment. During the initial three vials, your injections may be given two to five times weekly, allowing at least an 18-hour interval between injections. It usually takes about 22 injections to complete the first three vials. After this. the frequency of injections will be reduced to once a week. Increases in the dose of extract given will continue until you reach your Maintenance Dose. You usually reach your Maintenance Dose five to six months after initiating treatment. After reaching your Maintenance Dose, you will continue injections at weekly intervals for approximately 6 to 12 months. If your response is excellent at the end of that time, the frequency of your injections will be reduced to every two weeks for the next year. The frequency of your injections will then be decreased to once every three weeks the following year, and every four weeks the year thereafter. At the end of the fourth year. we will consider stopping the immunotherapy completely, depending on your clinical response to it. Ordinarily, one should have remained without symptoms or at least readily controlled with simple medications for two consecutive years before discontinuing immunotherapy. After immunotherapy is discontinued, the duration of benefits will vary from one individual to another. In general, the longer one remains or immunotherapy, the longer the beneficial effects last. Occasionally, some individuals may notice a flare-up of their allergy symptoms when the interval between their injections is increased. These individuals often choose to continue their allergy injections indefinitely at whatever interval is necessary to control their symptoms. If one fails to show a beneficial response after being on the Maintenance Dose at weekly intervals for approximately one year, the immunotherapy program will be discontinued at that time. Fortunately, this rarely happens.

QUESTIONS FREQUENTLY ASKED ABOUT ALLERGY INJECTIONS

1. WHEN CAN ONE EXPECT RESULTS FROM ALLERGY INJECTIONS?

   Allergy injections may take several months to be effective. Patience is in order. The best response to immunotherapy occurs as you reach the higher doses of extract. Therefore, judgment of the effectiveness of immunotherapy should be reserved until you have been on your Maintenance Dose for at least six months. (Please do not discontinue your injections without first discussing this with us.)

2. WHAT TYPE OF REACTIONS CAN OCCUR WHILE I AM TAKING ALLERGY INJECTIONS?

   Since you are being treated with substances to which you are allergic, allergic reactions to these injections can sometimes occur. The majority of these reactions are local reactions of no serious consequence. Very rarely, a reaction could be life-threatening. In order of decreasing frequency, the following types of reactions may occur while taking allergy injections.

   1. Local Reactions: These are the most common reactions. They are restricted to the area around the injection site. Two types of local reactions can occur, and the significance of each type differs, as noted below.

      Immediate Local Reaction: These are by far the most common reactions. They consist of redness, itching, and swelling occurring within 20 minutes at the site of the injection. They appear very similar to the reaction noted during allergy testing. As long as these reactions remain smaller than the size of a quarter, they are considered to be normal. Immediate reactions larger than a quarter should be reported to the doctor or nurse administering the injection so that your dosage schedule may be reduced accordingly. Should one have a large local reaction, an oral dose of an antihistamine and local application of ice will help minimize the swelling and itching. These reactions will usually disappear within one to two hours.

      Late Local Reaction (LLR): These reactions usually begin 2 to 8 hours after an injection and can last for up to 24 hours. These reactions are relatively common and may consist of redness, swelling, and soreness of the arm. These reactions are generally not related to your allergic sensitivity and, therefore, do not appear to predict difficulty with future allergy injections as far as systemic reactions are concerned. As long as these reactions do not become too uncomfortable, we recommend proceeding with immunotherapy as scheduled. If they cause too much discomfort, your extract dose can be reduced according to the recommendations on your Allergen Immunotherapy Tentative Dosage Schedule.

   2. Generalized or Systemic Reaction: All patients should be aware that there is a minimal risk (less than 1%) of an adverse general reaction to allergy injections. These reactions usually occur within 20 minutes following an allergy injection and include: (listed by increasing severity) : sneezing, generalized itching(eyes, nose, throat, hand, scalp, etc.), generalized hives, swelling or flushing, wheezing and/or shortness of breath, swelling of the throat, and allergic shock. These reactions are usually easily reversed by prompt treatment with an adrenaline injection, etc., by your physician. However, in rare cases (approximately out of every 7 million allergy injections), a generalized systematic reaction may cause death. Since most systemic reactions occur within a few minutes following an allergy injection, all patients must remain in the physician's office for at least 20 minutes following their injections. Should a generalized systemic reaction occur after leaving the office, return to the physician's office or the nearest hospital emergency room for an adrenaline injection and additional therapy if needed to reduce the symptoms. Should any patient not heed this direction, they are doing so at their own discretion and responsibility. Following a generalized systematic reaction, the allergen injection schedule must be reduced accordingly.

3. WHO SHOULD ADMINISTER ALLERGY INJECTIONS?

   Allergy injections must never be administered by anyone other the physician or member of his staff under his supervision. For your convenience, we give allergy injections in our main office and several satellite offices. The hours and locations of our injection offices are listed at the front desk of the main office. In each of our satellite clinics, a physician in the building is under contract with our office to treat you should you have a reaction to an injection. If you receive injections elsewhere, they must be given under a doctor's supervision. Do not put a friend or neighbor in the medicolegal situation of administering your allergy injections with the possibility of a reaction occurring.

4. WHAT HAPPENS IF AN INJECTION IS MISSED?

   No harm is done in missing an occasional injection. If the interval between injections during your build-up is two to four weeks, the last dose must be repeated before resuming your schedule. If the interval between injections exceeds four weeks, your dosage must be temporarily reduced according to the recommendations on your Allergen Immunotherapy Tentative Dosage Schedule.

5. WHAT SHOULD ONE DO WHEN AWAY ON VACATIONS? Because of the time and expense involved, we advise patients not to take allergen extracts on vacation or business trips for administration by out-of-town physicians unless they plan on being away for greater than two months. If any major change in the treatment schedule is contemplated because of prolonged travel, this should be discussed with the allergist in detail.

6. HOW LONG IS THE EXTRACT GOOD?

   Allergen extract can be used for one year following its preparation. No extract should be taken after one year. Please observe the expiration date on your allergy extract vials.

ADDITIONAL COMMENTS REGARDING ALLERGY INJECTIONS:

1. Medications may be taken as usual on the day of an injection.

2. Injections should be omitted if you are coughing, wheezing, or have a fever greater than 100°F orally.

3. If large immediate local or generalized systemic reactions occur after an allergy injection, your dosage schedule must be reduced accordingly.

4. Allergen extract should be refrigerated as much as possible. However, brief periods at room temperatures are acceptable. If extract freezes in the mail, it may still be used.

5. If allergen extracts are administered through the facilities of one's family physician or pediatrician, the allergist will supply the necessary extracts to the patient, including a dosage schedule and instructions for administration. Should there be any questions the physician should never hesitate to call the allergist's office. Your first allergy injection must be given in our office. Our nurses will instruct you in the necessary precautions to be observed while on immunotherapy.

6. Beta-blocker drugs must be avoided while receiving allergen immunotherapy. Although systemic allergic reactions to immunotherapy are not frequent, they may potentially occur with greater frequency and be more difficult to treat in patients receiving Beta-blocker drugs for high blood pressure, heart conditions, migraine headaches, and glaucoma. Therefore, we refrain from using Beta-blockers. However, such individuals must discuss these matters with the physician prescribing the Beta-blockers prior to changing it. Commonly-used Beta-blockers include: Betagan, Betopiic, Blocadren, Cartrol, Corgard, Corzide, Inderal, Inderide, Kerlone, Levatol, lopressor, Normodyne, Trandate, and Visken. Refer to Avoidance of Beta-Blocker Medications While on Allergen Immunotherapy -Tip #5 for additional information. Beware of new Beta-blockers that may become available in the future.

7. During pregnancy and the immediate period thereafter, a revised lower dosage schedule may be recommended. Therefore, please contact us for further directions as soon as you know that you are pregnant. Allergen injections can be continued throughout your pregnancy.

8. May we suggest that you keep this information in a "handy spot" at your home for future reference.

Approximately once a year, each patient receiving allergen injections will receive a notice to schedule an "Interval Summary" appointment to review one's progress, changes in medical status, and to plan for the next year of immunotherapy. It is essential that each patient receive yearly follow-up appointments while on immunotherapy. Allergen injections may need to be temporarily suspended if this review is not completed.