Presentation on theme: "Clinical process for properly prescribe allergen immunotherapy"— Presentation transcript:
1 Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MDProfessor of pediatrics, Allergy& ImmunologyState University of Tamaulipas, School of Medicine
2 Clinical process for properly prescribe allergen immunotherapy Summary Statement 80: The efficacy of immunotherapy depends on achieving an optimal therapeutic dose of each of the constituents in the allergen immunotherapy extract. ACox L, Nelson HS, Lockey RF. Journal of Allergen immunotherapy: A practice parameter third update Allergy Clin Immunol 2011;127:S1-S46
3 Allergen immunotherapy: What can and cannot be mixed. Esch RE Allergen immunotherapy: What can and cannot be mixed? Esch RE. J Allergy Clin Immunol 2008;122:
4 Clinical process for properly prescribe allergen immunotherapy CASE 1: M.D.K. Male. 16 years of agePrevious history: Cow’s 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.
6 Case 1: M.D.K.1. What allergens to be included?2. How many in one vial?3. Can we mix this unrelated allergens?
7 Decision must be based on the allergen which causes: 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 year2. The most severe symptoms3. A major impact on quality of life4. Which is more difficult to avoid
8 CASE 1: M.D.K. House dust mites…Related to perennial symptoms Tree pollens… Late winter to early SpringGrass pollens…Late Spring to early SummerWeed pollens…Summer to early Autumn
9 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: 1:200V1 X C1 = V2 X C2 Were:V1 = Final volume to prepareC1 = Desired concentration of extractV2 = Volume of extract needed (unknown)C2 = Concentration of extract you will use (manufacturer concentrate)JACI. 2011;127:S1-S46
10 CASE 1: M.D.K. Pollen SIT Pollen maintenance vial. Option: 5cc 1:200 w/v V2 = (V1/ C1)xC2V2 (?) = (5cc / 1/200)x1:20 w/v = (5/200)x20 = 0.5V2 = 0.5cc of each pollen extractMix of 5 pollen extracts: 0.5x5 = 2.5cc + 2.5cc of diluent.Option: 1:100V2 = (5/100)x20 = 1ccMix of 5 pollen extracts: 5cc no diluent.
11 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/mLEffective maintenance dose: 500 – 2000 AU or 10mcg/mL (Mf: 10mcg; MPt: 7 – 12 mcg/mL)Maintenance vial: 2000 AU/mL.V2 = (V1 x C1)/C2V2 (?) = (5cc x 2000)/10,000 AU = 1.0ccV2 = 1.0cc + 4cc Diluent ( 12mcg/mL; 6 mcg/dose)
12 Major allergen component in standarized extracts ConcentrationMajor componentContentEffective dose/projected dosePoa annua100k BAU/mLGroup 5320 μg/mL5 to 20µg/1000 to 4000AUAgropiron rep750 μg/mLPhleum PratPhl p5680 μg/mL20µg/Cynodon dact10k BAU/mLGroup 1300 μg/mLAmbrosia1:10 w/vAmb a 1290 μg/mL6 to 12µgD farinae60 μg/mL10 μgD pteronisinus65 μg/mL7 a 12 μgCatFel d 150 μg/mL15 μg
13 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.