Allergen Immunotherapy AIT Allergy Shots Group Education Allergy

Allergen Immunotherapy (AIT) “Allergy Shots” Group Education Allergy/ Immunology Service Department of Medicine Landstuhl Regional Medical Center

Objectives • Affirm that allergy shots are right for you • Discuss the risks, benefits, and expectations for allergy shots • Get you ready to embark on a life-changing therapy

Clinical Staff Lt. Col (Dr. ) Tyson Brown – Allergist, OIC* COL (Dr. ) Kirk Waibel - Allergist, TSgt Jennifer Mendiola--NCOIC* Ms. Laurie Kane- LVN* Ms. Lavivone Ritzade- LVN* Ms. Sherryann Cadet – LVN* SSgt Mary Berry* SGT Patricia Campos* SSgt Maria Szymanski* Frau Brigitte Carr/Frau Marion Heimbuck * Can administer allergy shots

Today’s Agenda Introduction “Why allergy shots? ” Your allergy shot prescription Safety and risk considerations with allergy shots • Goals of allergy shots • Check-in and screening process prior to getting injections. • Sign consent forms (IT, Epi-Pen) • •

Why Allergy Shots? • • • Allergic rhinitis Allergic conjunctivitis Allergic asthma Insect sting allergy Atopic dermatitis (eczema)*

Why Allergy Shots? • History of hay fever or allergic asthma • Demonstration of allergy by blood or skin testing • Several indications for allergy shots – Inadequate response to other treatments – Desire to reduce medication usage – Patient preferences – Goal to impact underlying disease as opposed to treat only the symptoms • Potential long-term benefit after 3 -5 year course of allergy shots

Your Allergy Shot Prescription • Military has contract with GREER® laboratories • Extract laboratory at Forest Glen, MD (USACAEL) prepares over 100, 000 individual vials per year • Tri-service and Do. D-VA sharing agreements and can ship worldwide

Your Allergy Shot Prescription • Individualized to you • Each vial has a schedule – “A” – 4 visits – “B” – 6 visits – “C” – 8 visits – “D” – 10 visits • Each vial up represents a 10 -fold increase in potency • Typical schedule: faster in the more dilute vials, slower in the more concentrated vials

Typical course • Initial buildup – 1 -2 times per week – 28 visits (approx 6 -9 months) • “Maintenance dose” – Administered every 2 -4 weeks • Refills – every 9 -12 months when the “old stuff” expires – Have to reduce dose slightly with refill and build back up to maintenance • Trial off shots after 3 -5 years of treatment

Safety and risks • Shot location – LRMC versus outlying clinic – Must take LRMC EDU class prior to starting allergy shots if you receive shots at LRMC – MUST wait in the clinic 30 minutes after injection – MUST have unexpired Epi-pen at time of visit • Local reactions – Injections are typically done on the upper arm – Local tenderness, swelling, redness common – No specific changes in schedule unless staff or patient concern

Asthma • Patients with asthma will be screened with a peak flow prior to giving allergy shot • Patients with poorly-controlled asthma are generally not started on allergy shots • Don’t expect to get an allergy shot if you are having a bad asthma day • Please don’t use your rescue inhaler just before coming so you can reach your peak flow (or afterwards secretly in the bathroom)

Pregnancy • Allergy shots can be continued, but not started, during pregnancy • Dose is not increased when pregnant • No greater risk for prematurity, abortion, or congenital anomaly when on allergy shots • Schedule an appointment with allergist if you become pregnant

Other medical conditions • How do these impact surviving anaphylaxis or potential side effects of epinephrine? • Certain medications – Beta-blockers, ACE-I • Coronary artery disease, arrhythmia • Cerebral vascular disease • Age - less than 5 years old; no upper age limit

Systemic reactions • Approximately 10 cases of death per 10 years from anaphylaxis after immunotherapy has been reported in the United States • 1 in 2. 5 million • Early 1990 s – Active duty soldier in Germany died from allergy shot reaction – No fatalities from military allergy shots in past 27 years (>10 million injections)

Systemic reactions • Prospective data collection from Oct 2013 – March 2017 for LRMC • 70 reactions in 11, 651 patients visits (19, 563 allergy shot injections) • 0. 36% per allergy shot – No deaths – No hospitalizations – 3 patients sent to ED for further evaluation • Most occurred during buildup in the yellow or red vials

Systemic reactions • 2/3 occurred within 30 minutes (some starting within 1 minute after injection) • 1/3 occurred between 30 -60 minutes • A few occurred between 1 -4 hours later • Requirement to have epinephrine autoinjector with you at the time of your allergy shot and for 4 hours afterwards

Systemic reactions • If you have left our clinic and have concerns, please call us, call 112, or go to the ED • If we are open, call us as we may recommend you come back to the clinic • Moved to the shot room • Epinephrine is administered in the upper thigh • An IV may be started • More than 1 dose of epinephrine may be required

Systemic reactions • Discourage vigorous physical activity within 2 hrs of allergy shot • Having a reaction doesn’t mean you have to stop shots – Usually able to reduce the dose and build back up – Repeated reactions, inability to reach reasonable dose, or really scary reaction may necessitate stopping permanently at a lower dose or discontinuing allergy shots

Symptoms of a reaction • Skin symptoms: itching, swelling, flushing, hives • Respiratory symptoms: cough, wheeze, throat tightness or throat clearing • GI symptoms: cramping, nausea, vomiting, diarrhea • Lightheadedness, “sense of impending doom”, metallic taste in mouth • Let us know

Consent form • Siblings of allergy shot patients are allowed • Adults who are getting their allergy shot may bring children > 8 yrs old • MUST WAIT 30 minutes in our clinic – Not in the hallway; not in the pharmacy – Not in the ICU – 2 strikes and you’re out – Emergencies can come up. Plan ahead if possible and let us know before leaving on your own

Annual visits • A required refill will prompt the staff to ask you to make a follow up visit with the allergist (every 9 -12 months) • Ensure patient satisfaction and safety with allergy shots • Reiterate trial off shots after 3 -5 yrs • Patients who stop allergy shots can still be followed in the clinic and potentially restarted on allergy shots if symptoms worsen off shots

Why aren’t shots effective? • Failure to remove significant exposures (pet) • Exposures to high levels of allergen • Continued exposure to nonallergic triggers (smoke, dust, weather changes) • Incomplete identification of relevant allergens • Failure to treat with adequate dose of allergen

Trial off shots • One-half to two-thirds of patients have longterm improvement • Worsening symptoms may take months to years • No current skin or blood test will identify who will succeed or fail a trial off shots

Your shot visit • • • Allergy shots are scheduled 0730 -1045 Monday and Wednesday 1300 -1545 Tuesday and Thursday We will be ready for you on your shot day 2 -patient identifier (National Patient Safety Goal)

Your shot visit • Sign your allergy shot form acknowledging you have looked at your vials • 6 questions: – Problem with your last allergy shot – Sick since your last allergy shot – Chance you could be pregnant – Problems with asthma – New medical conditions – Any new medications • Peak flow for patients with asthma or respiratory disease

Your shot visit • You will hold on to your shot folder for the 30 minute wait • Come find an allergy staff to check out • Make sure to make your next appointment prior to leaving and get a school excuse if needed

QUESTIONS?