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. 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. A
Cox 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 age
Previous 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.

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. 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 year
2. The most severe symptoms
3. A major impact on quality of life
4. 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 Spring
Grass pollens…Late Spring to early Summer
Weed 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: 1:200
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
Concentration
Major component
Content
Effective dose/projected dose
Poa annua
100k BAU/mL
Group 5
320 μg/mL
5 to 20µg/
1000 to 4000AU
Agropiron rep
750 μg/mL
Phleum Prat
Phl p5
680 μg/mL
20µg/
Cynodon dact
10k BAU/mL
Group 1
300 μg/mL
Ambrosia
1:10 w/v
Amb a 1
290 μg/mL
6 to 12µg
D farinae
60 μg/mL
10 μg
D pteronisinus
65 μg/mL
7 a 12 μg
Cat
Fel d 1
50 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 AU/mL = 680mcg of Phl p5/mL.
200 divided by 680 = 0.3cc + 4.7cc of diluent.