Presentation on theme: "Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of."— Presentation transcript:
Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of Tamaulipas, School of Medicine
Cox L, Nelson HS, Lockey RF. Journal of Allergen immunotherapy: A practice parameter third update Allergy Clin Immunol 2011;127:S1-S46 Summary Statement 80: The efficacy of immunotherapy depends on achieving an optimal therapeutic dose of each of the constituents in the allergen immunotherapy extract. A Clinical process for properly prescribe allergen immunotherapy
Allergen immunotherapy: What can and cannot be mixed? Esch RE. J Allergy Clin Immunol 2008;122:
CASE 1: M.D.K. Male. 16 years of age Previous history: Cows milk allergy in infancy. Hystory: 2 years, recurrent episodes of coriza, nasal congestion, acuous rhinorrea, epifora, fotofobia, intermitent dry cough. Symptoms, perenial with exacerbations in Winter, Spring and summer. Clinical process for properly prescribe allergen immunotherapy
Skin test. Case 1 M.D.K
Case 1: M.D.K. 1. What allergens to be included? 2. How many in one vial? 3. Can we mix this unrelated allergens?
Zuberbier T, Bachert C, Bousquet PJ, Passalacqua G, Walter Canonica G, Merk H, Worm M, Wahn U, Bousquet J. GA2LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma. Allergy 2010; 65: 1525–1530. Decision must be based on the allergen which causes: 1. The longest duration of symptoms per year 2. The most severe symptoms 3.A major impact on quality of life 4. Which is more difficult to avoid
House dust mites…Related to perennial symptoms Tree pollens… Late winter to early Spring Grass pollens…Late Spring to early Summer Weed pollens…Summer to early Autumn CASE 1: M.D.K.
CASE 1: M.D.K. Pollen SIT Quercus, Celtis, Sorgum, Ambrosia, Rumex Pollens probably effective dose range: 5 – 20 mcg (1:100 – 1:200 w/v) 5 pollen mix will dilute each other times 5. Maintenance dose Vial: 1:200 V1 X C1 = V2 X C2 Were: V1 = Final volume to prepare C1 = Desired concentration of extract V2 = Volume of extract needed (unknown) C2 = Concentration of extract you will use (manufacturer concentrate) JACI. 2011;127:S1-S46
CASE 1: M.D.K. Pollen SIT Pollen maintenance vial. Option: 5cc 1:200 w/v V2 = (V1/ C1)xC2 V2 (?) = (5cc / 1/200)x1:20 w/v = (5/200)x20 = 0.5 V2 = 0.5cc of each pollen extract Mix of 5 pollen extracts: 0.5x5 = 2.5cc + 2.5cc of diluent. Option: 1:100 V2 = (5/100)x20 = 1cc Mix of 5 pollen extracts: 5cc no diluent.
CASE 1: M.D.K: H.D.Mites or standarized Immunotherapy Mites maintenance vial F/Pt mix 50/50. Manufacturer concentrate: 10,000; 30,000 AU/mL Effective maintenance dose: 500 – 2000 AU or 10mcg/mL (Mf: 10mcg; MPt: 7 – 12 mcg/mL) Maintenance vial: 2000 AU/mL. V2 = (V1 x C1)/C2 V2 (?) = (5cc x 2000)/10,000 AU = 1.0cc V2 = 1.0cc + 4cc Diluent ( 12mcg/mL; 6 mcg/dose)
Major allergen component in standarized extracts ExtractConcentrationMajor componentContent Effective dose/projected dose Poa annua100k BAU/mLGroup 5320 μg/mL 5 to 20µg/ 1000 to 4000AU Agropiron rep100k BAU/mLGroup μg/mL5 to 20µg/ 1000 to 4000AU Phleum Prat100k BAU/mLPhl p5680 μg/mL 20µg/ 1000 to 4000AU Cynodon dact10k BAU/mLGroup 1300 μg/mL 5 to 20µg/ 1000 to 4000AU Ambrosia1:10 w/vAmb a μg/mL 6 to 12µg 1000 to 4000AU D farinae10k BAU/mLGroup 160 μg/mL 10 μg D pteronisinus10k BAU/mLGroup 165 μg/mL 7 a 12 μg Cat10k BAU/mLFel d 150 μg/mL 15 μg
Dose of Major component in mcg/mL Suppose 5cc maintenance dose vial for 10 doses of 0.5cc with Timothy grass pollen. 5cc must contain 10 times the maintenance dose. Example: Timothy grass maintenance effective dose 20mcg/mL Phl p5. 5 cc maintenance vial must contain 200mcg. Manufacturer label AU/mL = 680mcg of Phl p5/mL. 200 divided by 680 = 0.3cc + 4.7cc of diluent.