Zuberbier T, Canonica GW, da Silva B.
Specific immunotherapy with allergens: an important tool in the treatment of the allergic diseases.
J Dtsch Dermatol Ges. 2012 Dec;10(12):879-86.
· Specific immunotherapy (SIT) is a treatment in which specific allergens are administered to individuals who are allergic to these allergens. The goal of SIT is to reach a maintenance dose that modulates the immunological system and allows the allergen to be tolerated.
· Tolerance that is produced by SIT is caused by the increase in CD4+ CD25+ regulatory T cells.
· The success of SIT depends on the use of standardized extracts for which the potency and the relevant allergenic compounds are known.
· There is no universally accepted standard for measuring allergen content. Many laboratories use in-house reference materials.
· SIT is indicated for IgE-mediated diseases, such as moderate-severe allergic rhinitis, rhinoconjunctivitis, and controlled allergic asthma.
· Contraindications to SIT: malignancies, a forced expiratory volume in 1 second (FEV1) of less than 70 % of the predicted value, uncontrolled asthma, and acute infections, such as a cold with a fever.
· The use of beta-blockers should be substituted because they decrease the appropriate response to adrenaline in the case of a systemic reaction.
· SIT should be prescribed by a physician experienced in this treatment.
· The following allergens have been successfully used: birch, hazel, olive, ash, grass, cypress, cat dander, Parietaria, mugwort, ragweed, Dermatophagoides pteronyssinus, D. farinae.
· The GA2LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma does not recommend the use of mixtures of unrelated allergens since this leads to dilution.
· Each bottle should contain the patient’s name and date of birth, the allergens contained in the mixture, the manufacturing and expiration date, and the route of administration. The bottles should ideally be labeled in different colors.
· The patient should receive written information on the vaccine, the expected symptoms, and the possible complications and be asked for informed consent.
· Among asthmatic individuals, the patient’s peak expiratory flow should be measured before the application; the SIT should be suspended when the value is below the predicted value.
· If effective, the SIT for inhalant allergens should continue for 3 years.
· SIT effectiveness in the individual patient however depends on the correct indications.
· The standardization of the extracts, and the dosage are crucial.
· Local reactions occur at the application site in 26–82 % of patients.
· Subcutaneous nodules may form at the location of SCIT application, especially when aluminum-adsorbed vaccines are used. These nodules may persist and disappear after a few weeks. There is no need to adjust the SIT dosage, but one should consider to switch to a vaccine that does not contain aluminum.
· The prevalence of systemic reactions to conventional SCIT is less than 1 % especially when allergoids are used but may reach 34 % in patients receiving rush SIT.
· The severity of the reaction is related to the speed at which the symptoms appear following the application.
· The following are considered to be risk factors for systemic reactions: uncontrolled bronchial asthma and a FEV1 that is 70 % of the predicted value; the use of beta-blockers; high doses of potent, standardized vaccines for inhalable allergens; rush SIT with insect venom or inhalable allergens; the incorrect application technique; a dosage error; and administration of allergen during a period of exacerbated symptoms.
· Pre-medication, such as antihistamines, may be used.
· Pre-treatment with omalizumab has been demonstrated to increase the safety of rush SIT.
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