Allergen Immunotherapy Paper

Ashley Tobalsky

Allergen Immunotherapy Allergen immunotherapy is established through a series of shots that contain certain pure allergens at an increasing level in order to desensitize the patient and achieve life-long relief of allergy symptoms. Patients eligible for this treatment are those who suffer from year-round allergies, have controlled allergy-induced asthma, are allergic to bee stings, or can’t find relief for seasonal allergies through prescription medications. The practice of allergy-specific immunotherapy of desensitization dates back to 1911. At the St. Mary’s Hospital in London, England, two doctors, Noon and Freeman, successfully treated hay-fever sufferers by injecting them with pollen extracts. The practice continued to be used even thought it was very controversial and unpopular. In 1986 the British Medical Journal published a report cautioning against the use of immunotherapy in general practice and cited 26 anaphylactic deaths over 30 years. The deaths were a result of inappropriate treatment in patients with uncontrolled asthma. The newly introduced risks of death led to even more controversy and higher need for regulation of the practice. New regulations were soon introduced calling for careful patient selection along with stricter observation periods, greatly reducing all risks of death. The recent episodes of death related to allergen immunotherapy include the death of a 13year old girl who received her last allergy injection in May of 1998. She died from anaphylactic shock within 20 minutes after her injection because no one had stopped in to check on her. Shortly after that case a 41-year old mother died, also from severe anaphylaxis reaction. However, she was checked on, but the tiny clinic just didn’t have the correct treatment options available (Putman and Badzek, 2005).

These episodes, along with others, pushed for higher guidelines to be set by the American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI). These guidelines are established by board-certified specialists in allergy and asthma treatment, and also other personnel who practice under the direct supervision of allergists (ed. Cox, 2007). The revised and currently used procedure begins when the patient finds an allergy specialist that will recommend the treatment. Qualified patients with asthma should have symptoms under control. Allergy tests are given to determine what the patient is allergic to and which allergens will need to be included in the vile for each shot. This is done through either a skin prick test or a blood test. The next step involves the patient’s insurance company’s willingness to cover the cost of the treatment; whether they see it as necessary or experimental. Once all is settled, treatment may begin. Depending on the clinic, the patient may receive “traditional” treatment (conventional allergen vaccination) or “rush” treatment (rush allergen vaccination). Rush treatment completes the first nine months of traditional treatment in one day. Numerous shots are given in increasing doses while time is taken between each to supervise. After the initial day it takes about two additional months to build up to the maintenance level. It makes for a long day and a lot of exposure to allergens, but it saves money, about nine months to a year of shots with the traditional treatment, and some studies prove that it’s safer. A study of rush allergen vaccination (RAV) was presented at the annual meeting of the American College of Allergy, Asthma and Immunology, Nov. 19, 2001 in Orlando, Florida. It was done by several doctors, led by Dr. Smits, of allergy and asthma clinics in Indiana. Rush treatment was tested on 137 patients, male and female ranging from ages 2-68 years old. They all had a history of allergies and/or asthma, and patients with a history of anaphylaxis were

excluded. They were pretreated with prednisone and antihistamines up to two days before the RAV. The results showed some mild systemic reactions such as headache, abdominal pain, dizziness, itchiness, chest/throat tightness, cough and shortness of breath; all of which are consistent with the Conventional Allergy Vaccination (CAV) and easily treated with epinephrine, prednisone, or other medications (Smits et al., 2003). Overall RAV proved more efficient and also safer than CAV because of the pretreatment. The extended observation periods allow any reactions to be recognized and treated immediately. A time period ranging from half an hour to a full hour are taken in between sets of injections in order to watch for local (swelling around area of injection) and general (itchiness, runny nose, tightness of chest/troublesome breathing) reactions. If a significant reaction is noticed, treatment is given, injections may be stopped or the dosage of the injection may be steadied instead of increased. There is a wide range of costs for prescription drugs for the treatment of asthma and allergies. The price of a daily dose generic antihistamine for one month, without a deductable from insurance, is about $70. For a corticosteroid nasal spray, used everyday for a month, would be $102 without a deductable from insurance. And if you have asthma along with your allergies, you will also need a daily inhaler that can cost about $184 for a months worth of daily doses without a deductable from insurance. This adds up to $356 per month; $4,272 per year, and don’t think you won’t need it for the rest of your life. In fact, you may need to increase your doses as time goes by. Allergen Immunotherapy takes between three and five years to complete. After the first or second year the majority of patients are able to wean off of their prescription allergy and asthma medications. The first year of allergy immunotherapy injections has been estimated to

cost $800 for the initial year, and $170-$290 for subsequent years of maintenance therapy depending on the number of antigens and vials required (Fineman, MD., 1999). According to this, you can either pay thousands of dollars every year for prescriptions for the rest of your life or you can pay hundreds of dollars over a five year period and then ultimately be done with all costs of prescriptions and immunotherapy. A study was done by doctors at the Division of Allergy, Department of Pediatrics, at Cumhuriyet and Cukurova University’s Faculty of Medicine in Adana and Sivas Turkey. The objective of this study was to evaluate the effect of one year of house dust mite immunotherapy on the concentrations of three different immunologic markers. The effect on asthma symptoms was also compared with medication treatment. The patients included 31 mite-allergic, asthmatic children ranging from ages 6-16 years old. 19 were treated with allergen immunotherapy and the other 12 were controls, treatment was the usual prescription medication (Cevit et al., 2007). The results showed a significant improvement in asthma and allergy symptoms in the patients undergoing the allergen immunotherapy. In the control group no improvement was seen and their level of asthma and allergy symptoms remained constant. As far as the risks and benefits of allergen immunotherapy we have learned that there are indeed serious risks of this treatment that could lead to death if untreated. We also recognize that these risks are easily avoided if guidelines and regulations are followed. The benefits of allergen immunotherapy are exceptional as far as overall cost, no longer needing to pay for prescription medication; and efficiency, potential of allergies being completely cured is high. If children are treated early it could prevent new allergies from developing and also stop the onset of asthma. And lastly, it is often found that the overall quality of life in patients treated with allergen immunotherapy is improved resulting from a strengthened and more efficient immune system.

Ashley Tobalsky

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