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Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of.

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Presentation on theme: "Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of."— Presentation transcript:

1 Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of Tamaulipas, School of Medicine

2 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

3 Allergen immunotherapy: What can and cannot be mixed? Esch RE. J Allergy Clin Immunol 2008;122:659-60.

4 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

5 Skin test. Case 1 M.D.K

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 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

8 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.

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: 1:200 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

10 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.

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/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)

12 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 5 750 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 1 290 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

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 100000AU/mL = 680mcg of Phl p5/mL. 200 divided by 680 = 0.3cc + 4.7cc of diluent.


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