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![Page 1: Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of.](https://reader033.fdocuments.us/reader033/viewer/2022061305/5513fefe550346e2488b47e6/html5/thumbnails/1.jpg)
Clinical process for properly prescribe allergen immunotherapy
Noel Rodriguez-Perez, MDProfessor of pediatrics, Allergy& Immunology
State University of Tamaulipas, School of Medicine
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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
![Page 3: Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of.](https://reader033.fdocuments.us/reader033/viewer/2022061305/5513fefe550346e2488b47e6/html5/thumbnails/3.jpg)
Allergen immunotherapy: What can and cannot be mixed?
Esch RE. J Allergy Clin Immunol 2008;122:659-60.
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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.
Clinical process for properly prescribe allergen immunotherapy
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Skin test. Case 1 M.D.K
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Case 1: M.D.K.
1. What allergens to be included?2. How many in one vial?3. Can we mix this unrelated allergens?
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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
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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.
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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
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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.
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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)
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Major allergen component in standarized extracts
ExtractConcentratio
nMajor
componentContent
Effective dose/projecte
d dose
Poa annua 100k BAU/mL Group 5 320 μg/mL 5 to 20µg/ 1000 to 4000AU
Agropiron rep 100k BAU/mL Group 5750 μg/mL
5 to 20µg/ 1000 to 4000AU
Phleum Prat 100k BAU/mL Phl p5 680 μg/mL 20µg/
1000 to 4000AU
Cynodon dact 10k BAU/mL Group 1 300 μg/mL5 to 20µg/
1000 to 4000AU
Ambrosia 1:10 w/v Amb a 1290 μg/mL 6 to 12µg
1000 to 4000AU
D farinae 10k BAU/mL Group 1 60 μg/mL 10 μg
D pteronisinus 10k BAU/mL Group 1 65 μg/mL 7 a 12 μg
Cat 10k BAU/mL Fel d 1 50 μg/mL 15 μg
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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.