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  • Allergen immunotherapy: a practice parameterEditors: James T. Li, MD, PhD; Richard F. Lockey, MD; I. Leonard Bernstein, MD;Jay M. Portnoy, MD; and Richard A. Nicklas, MD

    ContributorsThe Joint Task Force has made a concerted effort to acknowl-edge all contributors to this parameter. If any contributorshave been excluded inadvertently, the Task Force will ensurethat appropriate recognition of such contributions is madesubsequently.

    EditorsJames T. Li, MD, PhD; Rochester, MNRichard F. Lockey, MD; Tampa, FLI. Leonard Bernstein, MD; Cincinnati, OHJay M. Portnoy, MD; Kansas City, MORichard A. Nicklas, MD*; Washington, DC*This parameter was edited by Dr. Nicklas in his private

    capacity and not in his capacity as a medical officer withthe United States Food and Drug Administration (FDA).No official support or endorsement by the FDA is intendedor should be inferred.

    Associate EditorsWilliam E. Berger, MD; Mission Viejo, CAJoann Blessing-Moore, MD; Palo Alto, CAJean A. Chapman, MD; Cape Girardeau, MOMark S. Dykewicz, MD; St. Louis, MOStanley M. Fineman, MD; Atlanta, GARufus E. Lee, MD; Dothan, ALDiane E. Schuller, MD; Hershey, PASheldon L. Spector, MD; Los Angeles, CA

    Work GroupRichard F. Lockey, MD, Chair; Tampa, FLHugh H. Windom, MD; Sarasota, FLJonathan A. Bernstein, MD; Cincinnati, OHRoger W. Fox, MD; Tampa, FLMary L. Jelks, MD; Tampa, FLMichael J. Reid, MD; San Francisco, CAJohn W. Yunginger, MD; Rochester, MN

    ReviewersDonald W. Aaronson, MD; North Chicago, ILDavid I. Bernstein, MD; Cincinnati, OHLarry Borish, MD; Charlottesville, VALinda Cox, MD; Fort Lauderdale, FLClifton Furukawa, MD; Seattle, WADavid F. Graft, MD; Minneapolis, MNJohn M. Kelso, MD; San Diego, CAAlnoor Malick, MD; Houston, TXLouis Mendelson, MD; Farmington, CTRobert Miles, MD; Lynchburg, VAMichael Welch, MD; San Diego, CADavid Lang, MD; Cleveland, OHRichard Weber, MD; Denver, COGary N. Gross, MD; Dallas, TX

    EndorsementAllergen immunotherapy: a practice parameter has been

    reviewed and endorsed by the American Academy of Pe-diatrics.

    TABLE OF CONTENTSI. Preface .................................................................................................................................................... 2

    II. Algorithm and Annotations ......................................................................................................................... 5III. Immunotherapy Glossary ............................................................................................................................ 6IV. Introduction .............................................................................................................................................. 7V. Summary Statements .................................................................................................................................. 7

    VI. Mechanisms of Immunotherapy ................................................................................................................. 10VII. Allergen Vaccines .................................................................................................................................... 10

    VIII. Efficacy of Immunotherapy ....................................................................................................................... 13IX. Safety of Immunotherapy .......................................................................................................................... 13X. Patient Selection ...................................................................................................................................... 15

    XI. Allergen Selection and Handling ................................................................................................................ 16XII. Immunotherapy Schedules and Doses ......................................................................................................... 19

    XIII. Special Considerations in Immunotherapy .................................................................................................... 25XIV. Future Trends in Immunotherapy ............................................................................................................... 28

    VOLUME 90, JANUARY, 2003 1

  • The American Academy of Allergy, Asthma and Immunol-ogy (AAAAI) and the American College of Allergy, Asthmaand Immunology (ACAAI) jointly accept responsibility forthis publication. These clinical guidelines are designed toassist clinicians by providing a framework for the evaluationand treatment of patients and are not intended to replace aclinicians judgment or establish a protocol for all patients.Not all recommendations will be appropriate for all patients.Because this document incorporates the efforts of many par-ticipants, no individual, including anyone who served on theJoint Task Force, is authorized to provide an official AAAAIor ACAAI interpretation of these guidelines. Recognizing thedynamic nature of clinical practice and practice parameters,the recommendations in this document should be consideredapplicable for 3 years after publication. Requests for infor-mation about or an interpretation of these practice parametersshould be directed to the Executive Offices of the AAAAI,the ACAAI, and the Joint Council of Allergy, Asthma andImmunology (JCAAI). These parameters are not designed foruse by pharmaceutical companies in drug promotion.

    Practice Parameters Published by the Joint Task Force onPractice ParametersPractice parameters for the diagnosis and treatment of asth-ma: Joint Task Force on Practice Parameters, representing theAmerican Academy of Allergy, Asthma and Immunology,the American College of Allergy, Asthma and Immunology,and the Joint Council of Allergy, Asthma and Immunology. JAllergy Clin Immunol 1995:96:707870.

    Bernstein IL, Storms WW. Practice parameters for allergydiagnostic testing: Joint Task Force on Practice Parametersfor the Diagnosis and Treatment of Asthma. The AmericanAcademy of Allergy, Asthma and Immunology and theAmerican College of Allergy, Asthma and Immunology. AnnAllergy Asthma Immunol 1995;75:543625.

    Shearer WT, Buckley RH, Engler RJ, et al. Practice pa-rameters for the diagnosis and management of immunodefi-ciency. The Clinical and Laboratory Immunology Committeeof the American Academy of Allergy, Asthma and Immunol-ogy (CLIC-AAAAI). Ann Allergy Asthma Immunol 1996;76:282294.

    Practice parameters for allergen immunotherapy: JointTask Force on Practice Parameters, representing the Ameri-can Academy of Allergy, Asthma and Immunology, theAmerican College of Allergy, Asthma and Immunology, andthe Joint Council of Allergy, Asthma and Immunology. JAllergy Clin Immunol 1996;98:10011011.

    Leung DY, Hanifin JM, Charlesworth EN, et al. Diseasemanagement of atopic dermatitis: a practice parameter. JointTask Force on Practice Parameters, representing the Ameri-

    can Academy of Allergy, Asthma and Immunology, theAmerican College of Allergy, Asthma and Immunology, andthe Joint Council of Allergy, Asthma and Immunology. WorkGroup on Atopic Dermatitis. Ann Allergy Asthma Immunol1997;79:197211.

    The diagnosis and management of anaphylaxis: JointTask Force on Practice Parameters, American Academy ofAllergy, Asthma and Immunology, American College of Al-lergy, Asthma and Immunology, and the Joint Council ofAllergy, Asthma and Immunology. J Allergy Clin Immunol1998;101:S465S528.

    Li JT, Pearlman DS, Nicklas RA, et al. Algorithm for thediagnosis and management of asthma: a practice parameterupdate. Joint Task Force on Practice Parameters, representingthe American Academy of Allergy, Asthma, and Immunol-ogy, the American College of Allergy, Asthma and Immu-nology, and the Joint Council of Allergy, Asthma and Immu-nology. Ann Allergy Asthma Immunol 1998;81:415420.

    Dykewicz MS, Fineman S. Executive Summary of JointTask Force Practice Parameters on Diagnosis and Manage-ment of Rhinitis. Ann Allergy Asthma Immunol 1998;81:463518.

    Spector SL, Bernstein IL, Li JT, et al. Parameters for thediagnosis and management of sinusitis. J Allergy Clin Im-munol 1998;102:S107S144.

    Portnoy JM, Moffitt JE, Golden DB, et al. Stinging insecthypersensitivity: a practice parameter. J Allergy Clin Immu-nol 1999;103:963980.

    Executive Summary of disease management of drughypersensitivity: a practice parameter. Joint Task Force onPractice Parameters, the American Academy of Allergy,Asthma and Immunology, the American College of Al-lergy, Asthma and Immunology, and the Joint Council ofAllergy, Asthma and Immunology. Ann Allergy AsthmaImmunol 1999;83:S665S700.

    The diagnosis and management of urticaria: a practiceparameter. Part I: acute urticaria/angioedema. Part II: chronicurticaria/angioedema. Joint Task Force on Practice Parame-ters. Ann Allergy Asthma Immunol 2000;85:521544.

    These parameters are also available at http://www.jcaai.org.

    I. PREFACEThe objective of Allergen immunotherapy: a practice pa-rameter is to improve the practice of allergen immunother-apy for patients with allergic rhinitis, allergic asthma, andHymenoptera sensitivity. This parameter is intended to in-crease the appropriate use of allergen immunotherapy; reducethe underuse, overuse, and misuse of allergen immunother-apy; and establish guidelines for the safe and effective use ofallergen immunotherapy, while reducing unwanted and un-needed variation in immunotherapy practice.

    Allergen immunotherapy: a practice parameter was de-veloped by the Joint Task Force on Practice Parameters. Thethree major allergy and immunology societiesthe ACAAI,the AAAAI, and the JCAAIcharged the Task Force with

    This document was developed by the Joint Task Force on Practice Para-meters, representing the American Academy of Allergy, Asthma and Immu-nology; the American College of Allergy, Asthma and Immunology;