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Literature Reading
Desno Marbun
Pembimbing : dr Melati Sudiro, MKes, Sp THT-KL(K)
Faculty of Medicine Padjadjaran University
Dr. Hasan Sadikin General Hospital
Bandung
2014
History of Allergen Immunotherapy
During last 100 years : Emergence of an affective solution
allergen immunotherapy
2
History of Allergen Immunotherapy
1911 : The quest begins
Leonard Noon and John Freeman : the
founders
Showed efficacy of allergen
immunotherapy in seasonal allergic
rhinitis
-Patient injected with increasing doses
of pollen extract
3
Developments between 1911 and
1950
Greater understanding of mechanisms involved
5
1950 1980
7
Definition
Allergen Immunotherapy
Repeated administration of specific
allergens to patients with IgE-mediated
conditions for the purpose of providing
protection against the allergic
symptoms
and inflammatory reactions associated
with natural exposure to these
allergens.
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IMMUNOLOGIC RESPONSES TO
IMMUNOTHERAPY
10
IMMUNOLOGIC RESPONSES TO
IMMUNOTHERAPY
13
Clin Transl Allergy 2012 ; 2 : 2
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IMMUNOLOGIC RESPONSES TO
IMMUNOTHERAPY
17
Precautions
Exposure to adrenergic blocking agent is a risk factor for
more serious and treatment resistant anaphylaxis.
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SPECIAL CONSIDERATIONS IN IMMUNOTHERAPY
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IMMUNOTHERAPY SCHEDULES
Conventional
schedules
The The dose and concentration of
allergen immunotherapy extract
build-up are increase.
1-3 times per week.
phase 3-6 months
24
Rush schedules
25
Dose adjustments for
late injections
No evidence based guideline on
dose adjustments for missed
immunotherapy doses.
28
World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction
Grading System
Or
Conjunctival
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Conjunctival erythema, pruritus or
tearing
Other
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:
Stethoscope and sphygmomanometer
Tourniquet, syringes, hypodermic needles, and large-bore needles(14-
gauge)
Aqueous epinephrine HCL 1:1000wt/vol
Equipment to administer oxygen by mask
Intravenous fluid set-up
Antihistamine for injection (second-line agents for anaphylaxis , but H1
and H2 antihistamines work better together than ether one alone).
Corticosteroids for intravenous injection
Vasopressor
Equipment to maintain an airway appropriate for the supervising
physicians expertise and skill. 30
Glukagon kit available for patient receiving blocker
Management of immunotherapy-
induced systemic reactions
The first line treatment is epinephrine.
No Contraindication to epinephrine
administration in patients with anaphylaxis.
Delayed administration epinephrine
fatalities.
Epinephrine 1 : 1000 dilution 0,2-0,5 ml
should be administered every 5 minutes
(0,01 mg/kg max 0,3 mg/ dose in
children.
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Premedication reduce
local and systemic reactions
Antihistamine
Decreased LLRs and cutaneous symptoms of pruritus,
urticaria, and angioedema but not decrease respiratory,
gastrointestinal, or cardiovascular reactions.
Montelukast
Decreases the size of local reactions rush VIT.
Omalizumab
Improve the safety and tolerability of cluster and rush
immunotherapy schedules in patients with moderate
persistent asthma and allergic rhinitis.
- Objective :
Increase in allergen Spesific IgG
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Injection Technique
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Noninjection Routes of
Immunotherapy
Sublingual Immunotherapy
Indication :
- Inhalant allergens
- Ragweed and grass pollen
Adverse reactions
- local reactions : oral pruritus,
edema of the mouth
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Non-Injection or Local Routes -
1
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NOVEL FORMULATIONS: ALLERGOIDS AND ADJUVANTS
Evidence of
specificNO
IgE
antibodies. Test Not a candidate for
result correlate immunotherapy
with clinical
symptoms and 3
exposure? 2
YES
Assess
Risks, benefits and costs of appropriate management options
Immunotherapy
Allergen exposure reduction
Medications
Patient preferences
Response to prior treatment
Severity of disease
4
12 STEPS ALGORITHM FOR ALLERGEN
IMMUNOTHERAPY (CONT)
Is
immunotherapy Immunotherapy not
recommended
given
NO
for this patient? 6
5
Identify
Specific allergenic extracts
Starting dose and immunotherapy schedule
Maintenance concentrate
8
12 STEPS ALGORITHM FOR ALLERGEN
IMMUNOTHERAPY (CONT)
Administer Immunotherapy
Safety equipment and procedures in places
Medical personal appropriately trained to identify
and treat immunotherapy reaction.
At least 30 minutes wait in office after injection
9
Manage Reaction
Re Assess risk/ benefit
immunotherapy
Reactions to
Consider dose/schedule
immunotherap
adjustment
y injections? Consider discontinuing
10 Yes immunotherapy
11
NO
Follow up every 6 to 12 months while on immunotherapy or
more frequently for evaluation/management of
immunotherapy reactions and/or underlying allergic disease
or co-morbid conditions
Assess follow up
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KEY HIGHLIGHTS OF THE UPDATE
Pregnancy :
- Allergen immunotherapy can be
continued
but usually is not initiated
53
THANK YOU
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