1. Dana V. Wallace, MD Assistant Clinical Professor Nova Southeastern University Davie, Florida drdanawallace@gmail.com

2. ANAPHYLAXIS IN THE OFFICE ALLERGIST and Staff BE PREPARED Templates and Forms ARE IMPORTANT!

3. Templates & Forms for SIT  Cox, L., H. Nelson, et al. "Allergen immunotherapy: a practice parameter third update." J Allergy Clin Immunol 127(1 Suppl): S1-55. –http://www.jacionline.org/article/PIIS009167491001 5034/addons [jacionline] http://www.jacionline.org/article/PIIS009167491001 5034/addonshttp://www.jacionline.org/article/PIIS009167491001 5034/addons  www.acaai.org –(ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)  Kalier, M., Lockey, R., eds. Clinical Allergy and Immunology Series, 4 th Edition  www.drdanawallace.com

4. Discussing SCIT Treatment Option www.drdanawallace.com

5. SLIT Patient Info (Part 1)

6. SLIT Patient Info (Part 2)

7. SLIT Patient Info (Part 3)

8. SLIT Side Effects

9. Allergy Immunotherapy Consent process should discuss:  Treatment and alternatives  Potential benefit  Potential risks, giving frequency of adverse events, including death  Cost associated and coverage options  Anticipated duration of Tx  Office policies that affect Tx, e.g. waiting time, missed AIs Based on 2011 Immunotherapy PP

10. Consent to Allergen Immunotherapy www.acaai.org

11. CONSENT FORMS TO CONSIDER  Allergy testing & immunotherapy  Permission to treat a minor  Consent to take allergy vaccine out of office to another MD for administration  Consent from remote MD agreeing to administer AI  Privacy form to authorize info to specific people- e.g. child custody www.drdanawallace.com

12. Consent to take Allergen Extract Sets to another office www.acaai.org

13. Cross-reacting Allergens jacionline

14. Recommended Documentation SCIT Prescription (Rx) Forms  Purpose: –To define the contents of the allergen immunotherapy extract in enough detail that it could be precisely duplicated  Patient information: –Name, chart number (if applicable), birth date, telephone number (home/mobile), email, & picture –Name, chart number (if applicable), birth date, telephone number (home/mobile), email, & picture  Preparation information: –Name of person (& signature) preparing the allergen immunotherapy extract & date prepared –Vial name, by allergens included (e.g., Trees, Grass or abbreviations (e.g., T, G, with legend) –Vial name, by allergens included (e.g., Trees, Grass or abbreviations (e.g., T, G, with legend) jacionline

15. Recommended Documentation SCIT Prescription (Rx) Forms  Allergen immunotherapy extract content information for each allergen: –Common name or genus and species –Concentration of available manufacturer’s extract –Volume of manufacturer’s extract to add to achieve the projected effective concentration Calculate by dividing the projected effective concentration by the concentration of available manufacturer’s extract times the total volume Calculate by dividing the projected effective concentration by the concentration of available manufacturer’s extract times the total volume –Extract manufacturer & lot number, expiration date –Same detail for all mixes  Vial expiration date should not exceed of any of the individual components jacionline

16. SCIT Prescription Form jacionline

17. SCIT Prescription Form-completed jacionline

18. IMMUNOTHERAPY RX FORM MODIFIED BY DANA WALLACE,MD www.acaai.org (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)

19. Labels for allergen immunotherapy extracts  Each vial must have appropriate patient identifiers, e.g., name, number, DOB, picture  Contents, e.g, T, G, M, Df, D, etc.  The dilution from the maintenance concentrate (vol/vol) using color, numbers, letters  Expiration date of individual vial jacionline

20. Allergy Extract Vial Dilution & Labeling www.acaai.org

21. Allergy Extract Vial Dilution & Labeling www.acaai.org

22. Vial Labels www.acaai.org

23. Weekly Build-up Therapy jacionline

24. Cluster SCIT Schedule jacionline

25. SCIT Rush Immunotherapy Schedule www.acaai.org

26. SLIT Proposed Schedules

27. SCIT Administration Record  List info in separate columns –Date of injection –Arm administered –Delivered volume in mm –Currently on antihistamine (desirable)  Projected build-up schedule  Description of any reaction (details may appear on separate sheet  Peak flow- pre and post SCIT may be included jacionline

28. ALLERGY INJECTION ADMIN. FORM www.acaai.org (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)

29. SCIT Administration Record www.acaai.org

30. Health Screen Form (Pre SCIT)  Patient identifiers, date, baseline peak flow & BP, if advised to use antihistamines with SCIT  Records status of: –Asthma control, consider standardized instrument and Peak Flow pre and post –Beta-blocker use –Pregnancy or other recent health care status, including recent infection or allergy/asthma flare –Previous adverse reaction to SCIT –Consider BP measurement jacionline

31. Health Screen Form jacionline

32. PRE-INJECTION HEALTH SCREEN www.acaai.org

33. Preparing your office staff for ANAPHYLAXIS

34. ANAPHYLAXIS CART

35. Supplies and Equipment for Anaphylaxis Treatment in office “NECESSARY”  Stethoscope and sphygmomanometer  *Epinephrine 1:1000  Oxygen  IV Fluids  Tourniquets, syringes, hypodermic needles, large-bore needles ” “CONSIDER HAVING”  One-way valve facemask  Diphenhydramine inj.  Corticosteroids inj. “MAYBE”  Vasopressor (Dopamine)  Glucagon  Automatic defibrillator  Oral airway * Required 2011 JTF Anaphylaxis PP

36. ANAPHPYLAXIS CART INVENTORY AND UPDATE LIST 2005 www.acaai.org

37. ANAPHYLAXIS TREATMENT www.drdanawallace.com

38. Patient Name_______________________ TABLE OF ANAPHYLAXIS DRUGS www.drdanawallace.com

39. Anaphylaxis Simple TX Plan Treatment of Anaphylaxis in the Physicians Office Assess airway breathing, circulation, and orientation Inject epinephrine, 0.3 mg intramuscularly, in the vastus lateralis (lateral thigh) Activate emergency medical services (call 911 or local rescue squad)[Might delay, depending upon severity of reaction. DW] Place patient in recumbent position and elevate the lower extremities, as tolerated Establish and maintain airway Administer oxygen Establish an intravenous line for venous access and fluid replacement; keep open with normal saline [Might delay, depending upon severity of reaction. DW] Consider administration of nebulized albuterol, 2.5-5 mg in 3 mL of saline; repeat as necessary Consider administration of ancillary medications, such as H1, [H2]antihistamine, [and] or a systemic corticosteroid Modified from Cox, et. al. AAAAI/ACAAI JTF Report on omalizumab-associated anaphylaxis. J Allergy Clin Immunol. 2007 Dec;120(6):1373-7.

40. POST AN ANAPHYLAXIS PROTOCOL AND/OR ALGORITHM (in visible location ) 0.01 DrugDrugDrugDrug Start StrengthStart StrengthStart StrengthStart Strength AddAddAddAdd Final dilution or maxFinal dilution or maxA=adult, C=childA=adult, C=childFinal dilution or maxFinal dilution or maxA=adult, C=childA=adult, C=child Method of DeliveryMethod of DeliveryMethod of DeliveryMethod of Delivery FrequencyFrequencyFrequencyFrequency AdultAdult(A)(A)AdultAdult(A)(A) Child < 12 (C) Dose/kg ***Child < 12 (C) Dose/kg ***Child < 12 (C) Dose/kg ***Child < 12 (C) Dose/kg *** X wt in KGX wt in KGX wt in KGX wt in KG = Dose= Dose= Dose= Dose Epinephrine Aqueous (Epi)Epinephrine Aqueous (Epi)Epinephrine Aqueous (Epi)Epinephrine Aqueous (Epi) 1:10001:10001:10001:1000 1:10001:10001:10001:1000 I M la t e r a l t h i g h Q5 minQ5 minQ5 minQ5 min 0.3-0.5cc0.3-0.5cc0.3-0.5cc0.3-0.5cc X _____X _____X _____X _____ =______=______=______=______ cccccccc EPI-PENEPI-PENEPI-PENEPI-PEN 1:10001:10001:10001:1000 1:10001:10001:10001:1000 I M la t e r a l t h i g h Q5 minQ5 minQ5 minQ5 min SRSRSRSR JR <15 kgJR <15 kgJR <15 kgJR <15 kg <15 kg<15 kg<15 kg<15 kg.15.15.15.15 mgmgmgmg Epi IVEpi IVEpi IVEpi IV 1:10001:10001:10001:1000 0.1 + 10 cc Saline0.1 + 10 cc Saline0.1 + 10 cc Saline0.1 + 10 cc Saline 1:100,0001:100,0001:100,0001:100,000 IV #1IV #1Over 5 minutesOver 5 minutesIV #1IV #1Over 5 minutesOver 5 minutes 5- 1 5 m i n 7-10 cc7-10 cc7-10 cc7-10 cc 0.1cc 0.1cc 0.1cc 0.1cc X_____X_____X_____X_____ =______=______=______=______ cccccccc Epi IV after cardiac arrest, if not responding to aboveEpi IV after cardiac arrest, if not responding to aboveEpi IV after cardiac arrest, if not responding to aboveEpi IV after cardiac arrest, if not responding to above 1:10001:10001:10001:1000 1-3 cc+ 10-30 cc Saline1-3 cc+ 10-30 cc Saline1-3 cc+ 10-30 cc Saline1-3 cc+ 10-30 cc Saline 1:100,0001:100,0001:100,0001:100,000 IV #2IV #2Over 3 minutesOver 3 minutesIV #2IV #2Over 3 minutesOver 3 minutes 10-30 cc10-30 cc10-30 cc10-30 cc 0.1cc/kg to0.1cc/kg to0.3cc/kg0.3cc/kg0.1cc/kg to0.1cc/kg to0.3cc/kg0.3cc/kg X______X______X_______X_______X______X______X_______X_______ =______=______=______=______=______=______=______=______ cccccccccccccccc Epi IV after cardiac arrest, if not responding to aboveEpi IV after cardiac arrest, if not responding to aboveEpi IV after cardiac arrest, if not responding to aboveEpi IV after cardiac arrest, if not responding to above 1:10001:10001:10001:1000 3-5 cc+ 30-50 cc Saline3-5 cc+ 30-50 cc Saline3-5 cc+ 30-50 cc Saline3-5 cc+ 30-50 cc Saline 1:100,0001:100,0001:100,0001:100,000 IV #3IV #3Over 3 minutesOver 3 minutesIV #3IV #3Over 3 minutesOver 3 minutes 10-30 cc10-30 cc10-30 cc10-30 cc 0.3cc/kg to 0.3cc/kg to.5cc/kg.5cc/kg 0.3cc/kg to 0.3cc/kg to.5cc/kg.5cc/kg X______X______X______X______X______X______X______X______ =______=______=______=______=______=______=______=______ cccccccccccccccc Benadryl IV/IMBenadryl IV/IM(diphenhydramine)(diphenhydramine)Benadryl IV/IMBenadryl IV/IM(diphenhydramine)(diphenhydramine) 50 mg/ml50 mg/ml50 mg/ml50 mg/ml Max 24 hr A=400 mg C=300 mgMax 24 hr A=400 mg C=300 mgMax 24 hr A=400 mg C=300 mgMax 24 hr A=400 mg C=300 mg IM/IVIM/IVIM/IVIM/IV re p e a t re p e a t 1 x P R N t h e n q 6 h r 25-50 mg25-50 mg25-50 mg25-50 mg 1 mg /kg or1 mg /kg or2 mg /kg2 mg /kg1 mg /kg or1 mg /kg or2 mg /kg2 mg /kg X______X______X______X______X______X______X______X______ =______=______=_____=_____=______=______=_____=_____ mgmgmgmg Benadryl PO LiquidBenadryl PO Liquid(diphenhydramine)(diphenhydramine)Benadryl PO LiquidBenadryl PO Liquid(diphenhydramine)(diphenhydramine) 12.5 mg/ml12.5 mg/ml12.5 mg/ml12.5 mg/ml Max 24 hr A=400 mg C=300 mgMax 24 hr A=400 mg C=300 mgMax 24 hr A=400 mg C=300 mgMax 24 hr A=400 mg C=300 mg POPOPOPO Q6 hrQ6 hrQ6 hrQ6 hr 25-50 mg25-50 mg25-50 mg25-50 mg 1 mg/kg 1 mg/kg 1 mg/kg 1 mg/kg X______X______X______X______ =______=______=______=______ mgmgmgmg Z a n t a c I V / I M (r a n i t i d i n e H C l ) 25 mg/ml25 mg/ml25 mg/ml25 mg/ml 20 cc saline20 cc saline20 cc saline20 cc saline IV over 10-15 minutesIV over 10-15 minutesIV over 10-15 minutesIV over 10-15 minutes Q6 hrQ6 hrQ6 hrQ6 hr 50 mg50 mg50 mg50 mg 1 mg/kg1 mg/kg1 mg/kg1 mg/kg X______X______X______X______ =______=______=______=______ mgmgmgmg AlbuterolAlbuterolAlbuterolAlbuterol 2.5 mg in 3 ml2.5 mg in 3 ml2.5 mg in 3 ml2.5 mg in 3 ml.083%.083%.083%.083% NebulizedNebulizedNebulizedNebulized Q20 minQ20 minQ20 minQ20 min 2.5 mg2.5 mg2.5 mg2.5 mg 1.25-2.5 1.25-2.5 1.25-2.5 1.25-2.5 1.25-2.51.25-2.51.25-2.51.25-2.5 mgmgmgmg X o p e n e x (l e v a l b u t e r o l ).63-1.25 mg in 3 ml.63-1.25 mg in 3 ml.63-1.25 mg in 3 ml.63-1.25 mg in 3 ml NebulizedNebulizedNebulizedNebulized Q20 minQ20 minQ20 minQ20 min 1.25 mg1.25 mg1.25 mg1.25 mg 0.63-1.25 mg0.63-1.25 mg0.63-1.25 mg0.63-1.25 mg 0.63-1.25 0.63-1.25 0.63-1.25 0.63-1.25 mgmgmgmg A t r o v e n t (i p r a t r o p i u m b r o m i d e ) (i p r a t r o p i u m b r o m i d e ).02% in 2.5 ml vial.02% in 2.5 ml vial.02% in 2.5 ml vial.02% in 2.5 ml vial May add to Albuterol or XopenexMay add to Albuterol or XopenexMay add to Albuterol or XopenexMay add to Albuterol or Xopenex NebulizedNebulizedNebulizedNebulized Q6 hrQ6 hrQ6 hrQ6 hr 500 mcg=500 mcg=1 vial1 vial500 mcg=500 mcg=1 vial1 vial 250-500 mcg =250-500 mcg =½-1 vial½-1 vial250-500 mcg =250-500 mcg =½-1 vial½-1 vial 250-500 =250-500 =½-1 vial½-1 vial250-500 =250-500 =½-1 vial½-1 vial mcgmcgmcgmcg AminophyllineAminophyllineAminophyllineAminophylline 500 mg/10 ml500 mg/10 ml500 mg/10 ml500 mg/10 ml Add to 100 cc Saline, micro dripAdd to 100 cc Saline, micro dripAdd to 100 cc Saline, micro dripAdd to 100 cc Saline, micro drip IV over 30 minutesIV over 30 minutesIV over 30 minutesIV over 30 minutes 5 mg/kg5 mg/kg5 mg/kg5 mg/kg 5 mg/kg 5 mg/kg 5 mg/kg 5 mg/kg X______X______X______X______ =______=______=______=______ mgmgmgmg Ringer’s LactateRinger’s LactateRinger’s LactateRinger’s Lactate 1000 ml bags1000 ml bags1000 ml bags1000 ml bags IV infusion over first 60 minutesIV infusion over first 60 minutesIV infusion over first 60 minutesIV infusion over first 60 minutes Continue, but reduce after BP stableContinue, but reduce after BP stableContinue, but reduce after BP stableContinue, but reduce after BP stable 20-30 mg/kg 25% first 10 minutes20-30 mg/kg 25% first 10 minutes20-30 mg/kg 25% first 10 minutes20-30 mg/kg 25% first 10 minutes 30 cc/kg 30 cc/kg 30 cc/kg 30 cc/kg X______X______X______X______ =______=______=______=______ cccccccc H e s p a n (h y d r o x y e t h y l s t a r c h ) 500 ml500 ml500 ml500 ml IV infusion over first 60 minutesIV infusion over first 60 minutesIV infusion over first 60 minutesIV infusion over first 60 minutes 500 ml500 ml500 ml500 ml 30 cc/kg 30 cc/kg 30 cc/kg 30 cc/kg X______X______X______X______ =______=______=______=______ cccccccc Solu-MedrolSolu-MedrolSolu-MedrolSolu-Medrol 40 mg/ml40 mg/ml40 mg/ml40 mg/ml Max 2 mg/kg/24 hrMax 2 mg/kg/24 hrMax 2 mg/kg/24 hrMax 2 mg/kg/24 hr IV pushIV pushIV pushIV push Q6 hoursQ6 hoursQ6 hoursQ6 hours 1 mg/kg1 mg/kg1 mg/kg1 mg/kg 1 mg/kg1 mg/kg1 mg/kg1 mg/kg X______X______X______X______ =______=______=______=______ mgmgmgmg P e d i a p r e d (p r e d n i s o l o n e ) (p r e d n i s o l o n e ) 5 mg/5 ml5 mg/5 ml5 mg/5 ml5 mg/5 ml POPOPOPO ?repeat X1?repeat X1?repeat X1?repeat X1 25-50 mg25-50 mg25-50 mg25-50 mg 0.5 mg/kg 0.5 mg/kg 0.5 mg/kg 0.5 mg/kg X______X______X______X______ =______=______=______=______ mgmgmgmg MedrolMedrolMedrolMedrol 4 mg4 mg4 mg4 mg POPOPOPO ?repeat X1?repeat X1?repeat X1?repeat X1 20-40 mg20-40 mg20-40 mg20-40 mg 0.4 mg/kg0.4 mg/kg0.4 mg/kg0.4 mg/kg X______X______X______X______ =______=______=______=______ mgmgmgmg AtropineAtropineAtropineAtropine 0.5 mg/ml0.5 mg/ml0.5 mg/ml0.5 mg/ml Max 2 mg AMax 2 mg AMax 1 mg CMax 1 mg CMax 2 mg AMax 2 mg AMax 1 mg CMax 1 mg C Subcut.Subcut.Subcut.Subcut. Q10 min.Q10 min.Q10 min.Q10 min..3-.5 mg.3-.5 mg.3-.5 mg.3-.5 mg 0.02 mg 0.02 mg 0.02 mg 0.02 mg X______X______X______X______ =______=______=______=______ mgmgmgmg GlucagonGlucagonGlucagonGlucagon 1 mg/ml1 mg/ml1 mg/ml1 mg/ml IV over 5 minIV over 5 minIV over 5 minIV over 5 min In f u s i o n 1-5 mg1-5 mg1-5 mg1-5 mg <20 kg=.5 mg<20 kg=.5 mg >20 kg=1.0 mg >20 kg=1.0 mg<20 kg=.5 mg<20 kg=.5 mg >20 kg=1.0 mg >20 kg=1.0 mg.5-1.0.5-1.0.5-1.0.5-1.0 mgmgmgmg NaHCO3NaHCO3NaHCO3NaHCO3 50 mEq/50 ml50 mEq/50 ml50 mEq/50 ml50 mEq/50 ml 2nd dose ½ first dose2nd dose ½ first dose2nd dose ½ first dose2nd dose ½ first dose IVIVIVIV Q10 minQ10 minQ10 minQ10 min 50-100 mEq50-100 mEq50-100 mEq50-100 mEq 1 mEq/kg 1 mEq/kg 1 mEq/kg 1 mEq/kg X______X______X______X______ =______=______=______=______ mEqmEqmEqmEq

41. ANAPHYLAXIS TX RECORD www.acaai.org

42. WAO Grading System for SCIT Systemic Reactions: GRADE 1- one organ system 42  Cutaneous – Urticaria, generalized pruritus, flushing, or sensation of heat or warmth or – Angioedema (not laryngeal, tongue, or uvula) OR  Respiratory – Rhinitis symptoms (e.g., sneezing, rhinorrhea, nasal pruritus and/or nasal congestion or or – Throat clearing (itchy throat) or – Cough perceived to originate in the upper airway mot eh lung, larynx, or trachea Or – Conjunctival: erythema, tearing, or pruritus – Other: nausea, metallic taste, or headache

43. WAO Grading System for SCIT Systemic Reactions: GRADE 2  Symptoms/signs of more than one organ system present or  Lower respiratory  Asthma: cough, wheezing, SOB (e.g. < than 40% PEF or FEV1 , responding to inhaled bronchodilator) or  Gastrointestinal  Abdominal cramps, vomiting, or diarrhea Or Other: uterine cramps Patients may describe a feeling of doom Might include any of the symptoms listed in grade 1

44. WAO Grading System for SCIT Systemic Reactions: GRADE 3  Lower respiratory  Asthma (e.g. 40% PEF or FEV1  ) or  Upper respiratory  Laryngeal, uvula, or tongue edema with or without stridor Note:Might include any of the symptoms listed in grade 1 and 2 Patients may describe a feeling of doom

45. WAO Grading System for SCIT Systemic Reactions: GRADE 4  Lower or upper respiratory –Respiratory failure with or without loss of consciousness or  Cardiovascular –Hypotension with or without loss of consciousness Note:Might include any of the symptoms listed in grade 1, 2, and 3 Adults may describe a feeling of doom

46. WAO Grading System for SCIT Systemic Reactions: GRADE 5  Death [WeMustPrevent]

47. Thank You DANA WALLACE, MD drdanawallace@gmail.com www.drdanawallace.com MEDICALPROFESSIONAL (USER NAME) Allergy (PASSWORD)