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| Allergies/Immunotherapy |
All patients with allergies may not benefit from allergy injections. Some cases of chronic allergies and/or asthma are not caused by airborne allergens and thus patients will not benefit from allergy injections. In addition, a few cases which are due to allergies can be well treated by allergen avoidance like taking care of a pet. Whether allergen injections are warranted is best determined by an allergy specialist, after obtaining a careful history, physical examination and allergy tests. Allergies can develop at any age, even infancy. Skin testing can be done at any age, and allergy injections can be given to children as young as two (2) years of age. Allergy injections consist of the airborne allergens (antigen) to which a particular patient has been found sensitive in a purified and sterilized manner. This is a natural product and includes pollens, molds, dust mites, pet dander, or insect venom. Allergy injections, or allergen (any substance that causes an allergy) immunotherapy, are effective for the treatment of allergic rhinitis (allergy affecting the nose), allergic conjunctivitis (allergy affecting the eyes), allergic asthma and stinging insect hypersensitivity. Allergy injections may be effective for allergic skin conditions, but are never given for food allergies. Not always. We evaluate each patient individually, and in many cases, even if allergy injections are desired, if appropriate skin testing has been done in the last 12 months we can use those results to mix the allergen vials. We have tests for most of the common allergens that effect people living in Central Texas, including aeroallergens (any airborne allergen, such as pollen) plus environmental allergens, such as dust mites, cats and dogs. In addition, we test for the foods in which people have typical allergies, but can test for almost any suspected food allergy if a patient brings in that particular food. The injections stimulate the body’s protective mechanisms to produce immunity (protection) to the allergens by countering the antibodies the patient makes that cause the allergies. An adequate amount of each antigen (any substance that stimulates an immune response) is necessary for the treatment to be effective. If too little is given, the body will not be adequately stimulated to produce protective antibodies. This is the most studied and effective method for treating allergies, and it is the only method approved by the FDA in the United States. Certain enzymes present in mold extracts can digest pollens when combined in one vial, causing the pollens to be less effective for allergy injections. Thus we keep molds in one vial and pollens in another. Typically it takes several months before the allergy injections produce a noticeable effect. Protection against the effects of allergen exposure occurs usually after the higher dosages are reached. The step-wise manner of building up allergy injections is both a safety mechanism and how the injections work. Allergy medications are typically used to control symptoms until the allergy injections become effective, and can be reduced or stopped over time in most cases. Allergy injections lessen sensitivities. After 3-5 years of the allergy injections, allergies may not recur for years. Local reactions (mild soreness, redness, swelling, local heat and tenderness at the site of injections) are the most common side effects. These usually last less than a day and are easily treated with supportive care including antihistamines for itching and swelling, ibuprofen and cold compresses for pain. If these local reactions last longer than 24 hours or are greater than a half-dollar in diameter, then the injection schedule is adjusted to minimize these reactions. If they consistently occur with allergy injections, taking an antihistamine before coming in for the injection can be helpful, and will not stop the injection from working. These local reactions are evidence that the patient’s body is making immunity. Unfortunately, anaphylaxis (a systemic or severe allergic reaction) may also occur. These reactions can present with, but are not limited to, full body hives, swelling of any part of the body including the throat, sudden increase in allergy symptoms and/or asthma symptoms, flushing, increased heart rate, weakness, fall in blood pressure and fainting. For this reason, allergy injections are administered in the office and patients are observed for 30 minutes after each injection. Epinephrine (adrenaline) is the most effective therapy for these reactions and is given as a shot. Typically this in addition to antihistamines and sometimes breathing treatments for breathing difficulties is sufficient therapy, but on occasion more intensive treatment is required. Not necessarily, as anaphylaxis (a systemic or severe allergic reaction) is a known, yet very rare risk of allergy injections. However, with careful attention to details, the chances of anaphylaxis can be dramatically reduced, and adjustments to the dosing schedule are always made after any severe reaction to help avoid a repeat reaction. Of note, those patients that do undergo a severe allergic reaction to their injections demonstrate a large amount of allergic antibodies in their body, and stand to benefit the most in time from allergy injections. Allergy injections are divided into two phases, the buildup and then the maintenance phase. The buildup phase requires frequent injections of low doses of allergen (typically once weekly initially, but can also be given several times per week to reach maintenance sooner). Once maintenance (maximum dosing) is reached, the injections are spaced out to every two weeks and quickly to once per month. Consistent dosing is required for maximizing the safety and effectiveness of the shots. Severe reactions to the injections are more likely with infrequent dosing, and the maximum benefit of allergy injections cannot be attained unless the injections are received in a timely manner. In general, a three to five year course of allergy injectionss is recommended for maximum benefit. This period of time has been studied to provide the longest lasting improvement in allergic symptoms, which can persist long-term after the injections are stopped. If injections are given for less than three years, early relapse of symptoms is more likely to occur. In general, the first repeat skin testing if performed about 3-5 years into the course of getting allergy injections to evaluate how much your allergies have lessened through the injections. It is helpful to have this information at that time to help you decide if you should continue on your injections or try stopping them. In addition, in rare instances, patients on allergy injections feel their symptom improvement lessens over time, and this may be due to developing new allergies that are not covered by the current injections. This situation warrants repeat skin testing. No! This is the case for many reasons, but the main one is that in the event of anaphylaxis (a systemic or severe allergic reaction), the patient may become too ill to self-administer epinephrine rapidly and undertake other needed emergency measures. Additionally, we make every effort to determine if a patient should be receiving their scheduled allergy injections when they come in as certain conditions, like a flare in their asthma symptoms or particular illness may prevent them from getting a shot at that time until they are recovered. Majority of severe allergic reactions to allergy injections occur within the first 30 minutes after obtaining the injection. Thus, since we are better able to recognize and effectively treat a severe allergic reaction in our offices, it is highly advised to wait for the recommended time period before leaving. It is very important that if a patient develops anaphylaxis (a systemic or severe allergic reaction) after leaving our office, that they make us aware of it as soon as possible. Adjustments will be made in their injection schedule to attempt to prevent such a reaction from occurring again, and even though this may slow down their course of allergy injections, it is very important to do so. Because anaphylaxis (a systemic or severe allergic reaction) is a rare but possible side effect of receiving allergy injections and is best treated with epinephrine. This dangerous reaction can occur at any time and in any place, and a delay in getting epinephrine is avoided by the patient treating themselves. Of note, any time you use your EpiPen, you must immediately seek additional medical care. When you are having an asthma attack (even if it is mild), or are ill with a respiratory infection or significant full body illness like the flu. Yes, this will not make the allergy injection any less effective. In fact, we encourage patients to take an antihistamine before coming in to receive an allergy injection if they consistently experience large local reactions to their injections. Allergy injections are in may ways like medications, every person responds differently to treatments. Overall, the majority of patients do show improvement while receiving allergy injections. However, for some, it takes longer than for others to obtain noticeable benefit from the injections. Yes, but allergy injections are usually not started and dosing is usually not increased during pregnancy. However, allergy injections may be safely continued on the same dose until delivery, and then can increase once again if needed. Yes. It is recommended that beta-blockers (a class of heart medications) be avoided if you wish to begin receiving allergy injections. Allergy injections are generally avoided in patients with very low lung function (either chronic or acute), poorly controlled asthma, unstable angina (arterial blockage leading to chest pain or shortness of breath), recent heart attack, significant arrhythmia (irregular heartbeat), and uncontrolled hypertension (high blood pressure). Of note, under some circumstances, allergy injections may be indicated for high-risk patients, such as those with stinging insect hypersensitivities. This is because your immune system changes over time, and can develop an allergy to any pollen, medication, food, etc… that previously was tolerated without any issues. It is also possible to “outgrow” allergies, but this typically only happens to food allergies that are present when young but go away as you get older. It is recommended by the American Academy of Allergy Asthma & Immunology that patients receiving allergy injections be evaluated by their allergist at least every 6 to 12 months. This determines if the patient is tolerating the injections well and receiving the desired benefit, in addition to looking for other health issues that could potentially affect the course of allergy injections. Yes and yes. We have patients in similar situations where we have been able to successfully take over their allergy care which can include providing their allergy injections and many of our patients had to leave the area and were able to continue their course of allergy injections in a new location without any issues. The vials may expire anywhere from 3 months to 2 years, depending on the strength of the antigens. During the buildup stage not more than 14 days and during maintenance dosing not more than 4-5 weeks. If a patient misses more than the above mentioned time between doses, the dosage needs to be cut to prevent possible reactions. We also make dosing adjustments when a patient is starting a new vial (old one expired) due to the increased potency of newly mixed allergens. If the patient has not recieved an injection in 6 months the patient may need to be retested, have their allergen vials remixed, or simply discuss with their physician why they missed their injections for so long, and will compliance continue to be an issue or should allergy injections be continued. No. For safety and legal issues allergy injections can only be provided in a health care center where a physician (MD or DO) or physicians’ assistant (PA-C) or nurse practitioner (NP-C) is present and is authorized to treat an allergic reaction. |
| Asthma |
Asthma can first develop at any age if given the right conditions. It does run in families, so if there is a first-degree relative with asthma there is an increased chance of developing it yourself. However, even without a positive family history, an individual can have asthma if exposed to the right triggers, which can include certain illnesses, allergies, or even irritants such as chemical fumes or cigarette smoke. Proper control of asthma requires both a good clinical history in addition to actual lung function data that is obtained from routine spirometry. |
 | © 2009 Allergy & Asthma Center, PA |