clinical process for properly prescribe allergen immunotherapy
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Clinical process for properly prescribe allergen immunotherapy. Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of Tamaulipas, School of Medicine. Clinical process for properly prescribe allergen immunotherapy. - PowerPoint PPT PresentationTRANSCRIPT
Clinical process for properly prescribe allergen immunotherapy
Noel Rodriguez-Perez, MDProfessor of pediatrics, Allergy& Immunology
State University of Tamaulipas, School of Medicine
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
Allergen immunotherapy: What can and cannot be mixed?
Esch RE. J Allergy Clin Immunol 2008;122:659-60.
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
Skin test. Case 1 M.D.K
Case 1: M.D.K.
1. What allergens to be included?2. How many in one vial?3. Can we mix this unrelated allergens?
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
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.
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
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.
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)
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
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.