https://en.wikipedia.org/wiki/Yellow_jacket
Craig M. Moffat, MD, FACP, FAAAI
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Allergies to environmental inhalants such as pollens, molds, animals, dust mites, etc. are responsible for unpleasant and often debilitating symptoms in up to 30% of the American population. Known as hay fever, typical symptoms include nasal problems of stuffiness, congestion, runny nose, sneezing, itching, and eye problems of itching, tearing, redness. One of the most effective forms of treatment is allergy shots, or immunotherapy, since it can alter the course of the disease. Currently two types of immunotherapy are in use for inhalant allergies: injections (subcutaneous immunotherapy – SCIT), and drops under the tongue (sublingual immunotherapy – SLIT). This article is a review of a much larger report summarizing current practice in the US and Europe by the American and European Academies of Allergy reported this month in the Journal of Allergy and Clinical Immunology (see J Allergy Clin Immunol 2013;131:1288)
Indications:
Patients develop allergy sensitivity to these common airborne agents because of a genetic susceptibility to make inappropriate immune reactions against them. Immunotherapy is designed to induce immune tolerance to these agents, thus changing this abnormal immune response to a more normal one. As immunotherapy proceeds, one sees a variety of changes in the abnormal allergy immune response leading to improvement in symptoms. For decades, SCIT has been the standard of care in the United States, but in the last decade studies have been emerging primarily from Europe showing the effectiveness of SLIT as well
Side effects:
Adverse reactions may be local or involve the entire body ranging from mild to life-threatening anaphylaxis and even death. The frequency of serious reactions in patients receiving SCIT is 0.1% of injections, the majority occurring within 30 minutes necessitating giving them in a medical facility. Mainly in Europe, SLIT represents 80% or more of new immunotherapy treatments and has a better safety profile allowing it to be given at home. Side effects of SLIT include local mouth itching or mild swelling which improves as treatment progresses. No clear risk factors for serious reactions have been identified, but no deaths have been reported.
Dosing:
Because SCIT involves injections, the effective dose is 20 to 30 times less than the dose of SLIT. In the US, allergists will commonly include multiple allergens in dosing injections because people are typically sensitized to many agents, while SLIT therapy typically is used to treat single-allergen sensitization
Efficacy:
The duration of effectiveness of both SCIT and SLIT is 7-12 years after discontinuation. SCIT has a greater clinical benefit tha antihistamines, leukotriene inhibitors (montelukast) and topical nasal steroids. Recent large scale studies suggest SLIT has much the same relative clinical effect as SCIT, and both appear to prevent development of new allergies and reduce the likelihood of developing asthma. Patients who receive either SCIT or SLIT experience as much as 80% higher cost savings than medications alone 3 years after completing therapy
Summary:
While immunotherapy is effective, not all patients benefit the same, adherence is difficult, studies looking at the effectiveness of SLIT in patients with multiple sensitivities are few, and oral treatment extracts are not yet approved in the US but will likely become available in the not distant future. Comparative studies looking at large populations of SCIT and SLIT treatment need to be conducted in this country where multiple allergens are used in treatment. At this time, indications to consider immunotherapy include long-standing symptoms, broad seasons, strong positive skin test responses, inadequate response to medications, complications, and diminishing quality of life.
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Introduction
The concept behind immunotherapy (allergy shots) is that the immune system can be desensitized to specific allergens that trigger allergy symptoms.
The allergen(s) are identified through a combination of a medical evaluation performed by a trained allergist/immunologist and allergy diagnostic testing (skin or allergy blood tests).
Allergy immunotherapy is a proven effective treatment for allergic rhinitis (nasal symptoms), allergic asthma and stinging insect allergy. It also may be effective in some individuals with atopic dermatitis (eczema) if they have allergies to airborne allergens. Currently, immunotherapy for food allergies is not recommended and strict avoidance of the food is advised although investigations with oral desensitization for food allergies are in progress in the United States.
Immunotherapy can potentially lead to lasting remission of allergy symptoms, and it may play a preventive role in the development of asthma and new allergies.
Who Can Benefit From Allergy Shots?
Both children and adults can receive allergy shots, although it is not typically recommended for children under age five. This is because of the difficulties younger children may have in cooperating with the program and in articulating any adverse symptoms they may be experiencing. When considering allergy shots for an older adult, medical conditions such as cardiac disease should be taken into consideration and discussed with your allergist / immunologist first.
You and your allergist / immunologist should base your decision regarding allergy shots on:
• Length of allergy season and severity of your symptoms
• How well medications and/or environmental controls are helping your allergy symptoms
• Your desire to avoid long-term medication use
• Time available for treatment (allergy shots requires a significant commitment)
• Cost, which may vary depending on region and insurance coverage
Allergy shots are not used to treat food allergies. The best option for people with food allergies is to strictly avoid that food.
How Do Allergy Shots Work?
Allergy shots work like a vaccine. Your body responds to injected amounts of a particular allergen, given in gradually increasing doses, by developing immunity or tolerance to the allergen.
There are two phases:
• Build-up phase. This involves receiving injections with increasing amounts of the allergens about one to two times per week. The length of this phase depends upon how often the injections are received, but generally ranges from three to six months.
• Maintenance phase. This begins once the effective dose is reached. The effective maintenance dose depends on your level of allergen sensitivity and your response to the build-up phase. During the maintenance phase, there will be longer periods of time between treatments, ranging from two to four weeks. Your allergist / immunologist will decide what range is best for you.
You may notice a decrease in symptoms during the build-up phase, but it may take as long as 12 months on the maintenance dose to notice an improvement. If allergy shots are successful, maintenance treatment is generally continued for three to five years. Any decision to stop allergy shots should be discussed with your allergist / immunologist.
How Effective Are Allergy Shots?
Allergy shots have shown to decrease symptoms of many allergies. It can prevent the development of new allergies, and in children it can prevent the progression of allergic disease from allergic rhinitis to asthma. The effectiveness of allergy shots appears to be related to the length of the treatment program as well as the dose of the allergen. Some people experience lasting relief from allergy symptoms, while others may relapse after discontinuing allergy shots. If you have not seen improvement after a year of maintenance therapy, your allergist / immunologist will work with you to discuss treatment options.
Failure to respond to allergy shots may be due to several factors:
• Inadequate dose of allergen in the allergy vaccine
• Missing allergens not identified during the allergy evaluation
• High levels of allergen in the environment
• Significant exposure to non-allergic triggers, such as tobacco smoke
Where Should Allergy Shots Be Given?
This type of treatment should be supervised by a specialized physician in a facility equipped with proper staff and equipment to identify and treat adverse reactions to allergy injections. Ideally, immunotherapy should be given in your allergist / immunologist’s office. If this is not possible, your allergist / immunologist should provide the supervising physician with comprehensive instructions about your allergy shot treatments.
Are There Risks?
A typical reaction is redness and swelling at the injection site. This can happen immediately or several hours after the treatment. In some instances, symptoms can include increased allergy symptoms such as sneezing, nasal congestion or hives.
Serious reactions to allergy shots are rare. When they do occur, they require immediate medical attention. Symptoms of an anaphylactic reaction can include swelling in the throat, wheezing or tightness in the chest, nausea and dizziness. Most serious reactions develop within 30 minutes of the allergy injections. This is why it is recommended you wait in your doctor’s office for at least 30 minutes after you receive allergy shots.
Medical content developed and reviewed by the leading experts in allergy, asthma and immunology.
© 2012 American Academy of Allergy, Asthma & Immunology. All Rights Reserved.
Tired of your hay fever symptoms? Are the symptoms interfering with life? Consider allergy shots. Contact Dr. Moffat at 801-501-2130 for a consult today.
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