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Allergy immunotherapy

Allergy Immunotherapy in the College Health Setting New York State College Health Association 2010 ANNUAL MEETING Mary Madsen RN – BCAssistant Director, Clinical OperationsUniversity Health ServiceUniversity of Rochester

Allergies: immune system overreacts by producing antibodies called Immunglobulin E (IGE) these travel to cells and release chemicals, causing the allergic reactions ƒ Allergy shots (immunotherapy) are aimed at increasing your tolerance to allergens that trigger your symptoms ƒ Allergy shots work like a vaccine, your body responds to the increased injected amounts of a particular antigen and develops a resistance and tolerance ƒ Indicated for allergic asthma, allergic rhinitis/conjunctivitis, stinging insect allergy

ƒ The preferred location for administration is the prescribing physician's office, especially for high risk patients ƒ AIT must be initiated and monitored by an allergist
ƒ Pts. may receive AIT at another health care facility if the
physician and the staff are equipped to recognize and
manage systemic reactions
ƒ Full, clear, detailed immunotherapy schedule must be ƒ Constant, uniform labeling system for extracts, dilutions ƒ Procedures to avoid clerical/nursing errors (i.e. pt. photo ID) (file by DOB)

Issues in College Health Setting ƒ Information needed from allergistƒ Policies and procedures that increase safetyƒ Immediate and delayed reactionsƒ Recognition and treatment of anaphylaxisƒ Preparedness plan for educating staff

Immunotherapy Safety ƒ Incidence of fatalities has not changed much in the last 30 years in the US ƒ From 1990-2001 fatal reactions occurred at a rate of 1 per 2.5 million injections ƒ Most occur during maintenance phase or "rush" ƒ Poorly controlled asthmatics at greatest risk
ƒ Many deaths associated with a delay in
administering epinephrine or not giving it at all

Preparedness of health service ƒ Established medical protocols and treatment ƒ Stock and maintain equipment/suppliesƒ Physicians and staff maintain "clinical proficiency" in anaphylaxis recognition and management ƒ Consideration of drills tailored to assess skills, response, and preparedness of office staff ƒ Tailor drill to consider access to local EMS- response times vary by location

Patient Responsibility ƒ Patient must wait 20-30 minutes in officeƒ Those with prior systemic or delayed reactions should wait longer ƒ Compliance with injection scheduleƒ Report any reactions to PCP and allergistƒ Epi-Pen kits for self treatment

Local Reactions Are Common Redness, swelling, warmth at Measurement Scales ƒ Differ between ƒ Large, local, delayed reactions do not predict the development of severe systemic reactions ƒ Compare to coin ƒ Local reactions may affect ƒ Grade 1+ - 4+ ƒ Length of reaction Options for treating local reaction Don't need MD order antihistamine prior to Hydrocortisone to site ƒ Benedryl rinse Benedryl spray to site ƒ Epi rinseƒ Lowering doseƒ Halt dose increase during Benadryl or Epi Rinse Instructions ƒ Draw Benadryl into syringeƒ Pull plunger of syringe back until the entire barrel of syringe has been coated with ƒ Return Benadryl to original Benadryl ƒ Fill syringe with appropriate dose Systemic Reactions ƒ Incidence of systemic reactions ranges from 0.05% to 3.2% of ƒ Most occur during maintenance phaseƒ Poorly controlled asthmatics at greatest riskƒ Many deaths are associated with a delay in administering epinephrine or not giving at all ƒ Risk factors include: ƒ Dosing errorsƒ Symptomatic asthmaƒ High degree of allergy hypersensitivityƒ Use of beta blockers/ACE-Iƒ New vialsƒ Injections during the allergy seasonƒ Dosing protocols (rush regimens) Symptoms of Systemic Reactions ƒ Any allergic symptom that occurs at a location other than the site of the injection ƒ Chest congestion or wheezingƒ Angioedema-swelling of lips,tongue, nose, or throatƒ Urticaria, itching, rash at any other siteƒ Abdominal cramping, nausea, vomitingƒ Light-headedness, headacheƒ Feeling of impending doom, decrease in level of Anaphylaxis: potentially deadly allergic reaction that is rapid in onset, most commonly triggered by food, medication or insect sting ƒ Most common:ATB (penicillin, cephalosorins) Food (nuts, cows milk, seafood) ƒ Adolescents/young adults: foodsƒ Middle age: venom ƒ Older adults: medications Recognition of Anaphylaxis for college health, this isn't just for allergy injections! ƒ Most reactions (1/2 – 1/3) occur in 20-30 minutes of vaccine 10% 30 – 60 min (asthma with multiple injections Medication 10-20 min Insect sting 10-15 min Foods 25 – 35 min Late phase (8-12 hrs) reactions possible ƒ Prompt recognition of potentially life threatening reactions by staff and patients ƒ Urticaria/angioedema are the most common initial symptoms--but they may be absent or delayed Most Common Signs and Symptoms ƒ Skin: flushing, itching, urticaria: 90%ƒ Upper and lower airway signs: cough, wheezing, dyspnea, change in voice quality, feeling of throat closing: 70% ƒ GI symptoms: nausea, vomiting, diarrhea, crampy abdominal pain: 40% 5 Most Common Factors in Fatal Reactions ƒ Uncontrolled asthma (62%)ƒ Prior history of systemic reaction (53)ƒ Injections during peak pollen season (43%)ƒ Delay/failure in epi treatment (43%)ƒ Allergy injection given IM instead of SQ or dosing error (17%) Also: upright posture Recommended Equipment ƒ Stethoscope, BP cuff ƒ Diphenhydramine ƒ Tourniquet, large bore (oral and injection) IV needles, IV set-up ƒ Albuterol nebulized ƒ Aqueous epinephrine ƒ O2 and mask/nasal ƒ Oral airwayƒ Treatment log Immediate Intervention ƒ Assess ABC's
ƒ Administer epinephrine ASAP! There is no
contraindication ƒ Fatalities usually result from delayed
administration of epinephrine--with
respiratory, and cardiovascular complications
ƒ Subsequent care based on response to epinephrine ƒ 1:1000 dilution, 0.3 mg. dose administered IM or SQ q5 minutes as needed to control BP and other symptoms ƒ Tourniquet above injection siteƒ Pt can use their Epi-pen ƒ Effect of epi can be blunted by beta-blockers, with severe, prolonged sx including bronchospasm, bradycardia, and hypotension ƒ Glucagon can be used to reverse beta blockers IM vs. SQ Epinephrine ƒ Both routes of injection appear in the ƒ IM injections into the thigh have been reported to provide more rapid absorption and higher plasma levels than IM or SQ injections into the arm.
ƒ Studies directly comparing different routes have not been done ƒ Establish/maintain airwayƒ Give O2/check pulse oxƒ IV access, hang IV fluids with NSƒ Consider: ƒ Diphenhydramine 25-50 mg. IMƒ Albuterol nebulized ƒ Transfer to ED Measures to reduce dosing errors ƒ Educate staff administering ƒ Standardize forms & protocolsƒ Multiple identity checks: name/DOBƒ One patient in "shot" roomƒ Avoid distractions to staffƒ Patient education about systemic reactions Increase administration safety ƒ Detailed instructions from allergistƒ Develop own step by step process for giving ƒ Standardize forms to document injectionsƒ Standardize treatment for systemic reactionƒ Agreement form for student complianceƒ All staff competency and mock systemic reaction ƒ Review of health status before injections Review Health Status Before Injections (why you don't draw injection first) ƒ Current asthma symptoms, ? Measure peak flowƒ Current allergy symptoms and medication useƒ New medications (beta blockers, ACE-I)ƒ Delayed reactions to previous injectionsƒ Compliance with injection schedule ƒ New illness (fever), pregnancyƒ Consultation with allergist as needed ƒ Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility, ACAAI, October 1997.
ƒ Rank MA, Li JTC. Allergen Immunotherapy. Mayo Clin Proc. ƒ Stokes JR, Casale TB. Allergy Immunotherapy for Primary Care Physicians. ƒ Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis:an updated practice parameter. J Allergy Clin Immunology2005;115:S483-523.
ƒ Li JT, Lockey IL, Bernstein JM, et al. Allergen immunotherapy: a practice parameter. Ann Allergy, Asthma & Immunology.2003;90:1-40.

Source: http://nyscha.org/files/2010/handouts/Friday/FR-7.02%20Allergy%20Injections%20in%20College%20Health%20Setting.pdf