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Allergy Program Overview

C O N F I D E N T I A L

C O N T E N T3 : WELCOME LETTER

4 : ALLERGY

5 : SKIN TEST

6 : PREPARING FOR THE TEST

7 : WHO SHOULD GET TESTED

8 : SIDE EFFECTS

9 : CRASH CART

10 : TESTING PANEL

17 : READING RESULTS

18 : THERAPY

19 : ALLERGY IMMUNOTHERAPY

20 : WHO SHOULD & SHOULDN'T GET THERAPY

21 : TREATMENT VIALS

22 : PRESCRIPTIONS

23 : ALLERGY INJECTIONS

24 : MISSED PROTOCOL

25 : TREATMENT TRACKING

27 : HOME THERAPY

29 : ANAPHYLAXIS

30 : MANAGEMENT OF ANAPHYLAXIS

32 : OFFICE-BASED ANAPHYLAXIS ACTION PLAN

34 : FOOD ALLERGY TESTING

35 : IgE TEST

36 : IgG TEST

37 : ALCAT TEST

39 : FORMS

48 : RESOURCES

C O N T E N T

©Jortay 2018. All Rights Reserved. 3

On behalf of the entire Jor tay team, I 'd l ike to welcome your

pract ice to our valued family of c l ients . We know how impor tant

the decis ion of healthcare par tner is , and we great ly appreciate

you entrust ing our team. We wi l l work hard to always aff i rm your

decis ion to work with Jor tay.

This manual is to provide you with an over view of Jor tay 's al lergy

test ing and immunotherapy program. You, as the provide, are

responsible for making the best and most appropriate medical

decis ions for your pat ient . We wi l l modify our program to meet

the needs of your pract ice and patients .

Again, thank you for select ing Jor tay. We look for ward to

working with you and your pat ients .

WELCOME TO

JORTAY ALLERGY TESTING AND

IMMUNOTHERAPY PROGRAM


An al lergy occurs when a pat ient reacts to things l ike

pol len or cats that don't affect most people. I f the pat ient

comes into contact with something the pat ient is a l lergic to

(cal led an al lergen) , pat ient 's may have symptoms such as i tching

or sneezing. This is cal led am al lergic react ion.

WHAT IS AN ALLERGY?


SKIN TEST

A skin pr ick test checks for immediate al lergic react ions to many substances at once. A

skin pr ick test uses lancet 's that barely penetrate the skin's sur face and is not painful .

These tests are not ver y invasive, and, for most al lergens, they tend to produce quick

results . A di luted al lergen is appl ied using a smal l , disposable plast ic device to pr ick the

sur face of your skin. The medical ass istant wi l l draw smal l marks on the skin of the pat ient

and apply a drop of al lergen extract next to each mark . The lancet is then used to pr ick the

extracts into the skin's sur face.

Once the extracts have been administered the medical ass istant must then wait 15 to 20

minutes to look for symptoms. The medical ass istant wi l l begin to look for raised, red,

i tchy bump that may look l ike a mosquito bite . The larger the wheal (bump), the more

sensit ive the pat ient may be to the al lergen. I f the pat ient is a l lergic , the results wi l l be

recorded then the skin wi l l be whipped off and cleaned.


HOW SHOULD THE

PATIENT PREPARE FOR THE TEST?

Patient shouldn't take antihistamines for 3 to 7 days

beforethe test . ( I t 's okay to use nose [nasal] steroid sprays

and asthma medicines) . They wi l l not inter fere with skin

tests .

è H1 Antihistamines – Hold for 1 week before vis i t

- Zyr tec (Cetir iz ine) , Dimetapp, Patanase nasal spray

- Xyzal , Chlor-Tr imeton, Patanol eye drops

- Al legra (Fexofenadine) , Tavist , Tylenol Al lergy Sinus

- Clarat in (Loratadine) , Atarax (Hydroxyzine) , Optivar eye

drops

- Clar inex, Vistar i l , E lestat eye drops

- Benadr yl , Hismanal (Aztemizole) , Tylenol F lu Nightime

- Diphenylhydramine, Astel in nasal spray, Tylenol Cold and

Flu

- Act i fed, Astepro nasal spray, Dramamine/Mecl iz ine

è H2 blocking medications (for reducing stomach acid)

- Hold dose star t ing the evening before vis i t

- Pepcid (Famotidine) - Zantac (Ranit idine)

- Tagament (Cimetidine)

è Leukotriene blocking medications - Hold dose the

morning of visit

- Singulair (Monteleukast)

- Zyfo (Zi leuon)

- Accolate (Zafr lukast)


è Must be at least age 5

è Not currently taking al lergy medicine

è No histor y of anaphylactic shock

è Has not been tested for same allergens within the

last year

Skin tests are general ly accepted

for al l age groups. In cer tain

c ircumstances, though skin tests

are not to be administered.

Provider 's consent is required

before administer ing any test .

Some patients who have been

advised not to take the skin test

are pat ients who have had a

severe al lergic react ion, are on

medicat ions that can inter fere

with test results , have cer tain skin

condit ions, as wel l as any other

reasons that provider might have.

Here at Jor tay we have a few

guidel ines we fol low.

WHO SHOULD

AND SHOULDN'T

GET TESTED

Jortay Testing Requirements


Any medical test involves some r isk . The r isk

with al lergy skin tests is that al lergy symptoms

might occur during the test . The most common

symptoms are i tching and swel l ing of the skin

where the test was administered. In rare cases, a

more ser ious react ion can occur. That is why skin

tests should be done under provider 's

POTENTIAL SIDE EFFECTS

FROM ALLERGY SKIN TESTING


è Stethoscope

è Sphygmomanometer

è Injectable Epinephrine 1:1,000 or Epi Pens

è Oxygen

è Intravenous 0.9 normal (NL) sal ine

è 1-way valve facemask

è Orophar yngeal and nasal phar yngeal airways

è Disposable face masks

è Oxygen saturation monitor

è Albuterol inhalational solution (0.05%), glucagon

è Written emergency protocol and char t for tracking patient treatment

CRASH CART

While preparing for al lergy test ing one

can never know how a pat ient can react

to an al lergen. Therefore, to be safe,

we recommend the provider provide

a crash car t in the off ice.

We recommend the fol lowing items

to be included in the crash car t :

Here at Jor tay, we have several di f ferent test ing panels . We can test for common al lergies

such as dog, and cat al lergies , as wel l as test ing for several di f ferent types of molds.

TESTING PANEL


CAT FELIDAE A

DOG CANIDAE A

FEATHER MIX ANATIDAE A

HORSE EQUIDAE A

DUST MITE MIX DEMODICIDAE A

JOHNSON GRASS POACEAE A

IMAGE COMMON NAME FAMILY PANEL

POSITIVE CONTROL HISTAMINE


BERMUDA GRASS POACEAE A

SEVEN GRASS MIX POACEAE A

CLADOSPOR SPEAR

MOLD DAVIDIELLACEAE B

ALTERNARIA MOLD PLEOSPORACEAE B

A

TRICHOCOMACEAE BASPERGIL MIX MOLD

CLADOSPOR HERB MOLD DAVIDIELLACEAE B

BIPOLARIS MOLD PLEOSPORACEAE B

FUSARIUM MOLD MIX NECTRIACEAE B

NEGATIVE CONTROL




MUCOR LUS MOLD MUCORACEAE B

STERMPHYLL MOLD STACHYBOTRYS B

COCK ROACH MIX BLATTIDAE B

JUNIPER TREE MIX CUPRESSACEAE C

PENICILLMIX MOLD TRICHOCOMACEAE B

MELALEUCA TREE MYRTACEAE C

MESQUITE TREE FABACEAE C

OLIVE TREE OLEACEAE C

QUEEN PALM TREE ARECACEAE C



ASH TREE MIX OLEACEAE C

PEPPER TREE ANACARDIACEAE C

BIRCH TREE MIX BETULACEAE C

SWEET GUM TREE ALTINGIACEAE C

CEDAR RED TREE CUPRESSACEAE D

COTTON WOOD

EAST TREE SALICACEAE D

CYPRESS BALD TREE CUPRESSACEAE D

ELM AMER TREE ULMACEAE D

OAK EASTERN TREE MIX FAGACEAE D



HICKORY PECAN TREE MIX JUGLANDACEAE D

SYCAMORE AMER TREE PLATANACEAE D

WALNUT BLACK TREE JUGLANDACEAE D

WILLOW BLACK TREE SALICACEAE D

CEDAR RED TREE CUPRESSACEAE D

COCKLEBUR WEED ASTERACEAE E

FIREBUSH KOCHIA WEED AMARANTHACEAE E

DOCK SORREL WEED MIX POLYGONACEAE E

LAMIACEAE ESAGE WEED MIX



SCALE ATRIPLEX WEED AMARANTHACEAE E

RUSSIAN THISTLE WEED AMARANTHACEAE E

PIGWEED ROUGH AMARANTHACEAE E

RAGWEED MIX ASTERACEAE E

LAMBS QUARTER WEED AMARANTHACEAE E

CATTLE EPITHELIA BOVIDAE F

ACREMONIUM MOLD HYPOCREACEAE F

AUREBOSIDUM MOLD AUREOBASIDIACEAE F



CHATEOMIUM MOLD CHAETOMIACEAE F

BOTRYIS MOLD SCLEROTINIACEAE F

PLANTAIN ENGLISH WEED PLANTAGINACEAE E

HAMSTER EPITHELIA CRICETIDAE F

RABBIT EPITHELIA LEPORIDAE F

RAT EPITHELIA MURIDAE F

GUINEA PIG EPITHELIA CAVIIDAE F


Results of the al lergy test ing wi l l be presented to the providerby the medical ass istant

within 15 to 20 minutes af ter the test has been administered. A posit ive test result means

that a pat ient is a l lergic to a substance. A posit ive result wi l l be ref lected by a raised, red,

i tchy wheal that may look l ike a mosquito bite . Posit ive response is def ined as a wheal

greater than 99% of wheals generated by the administrat ion of sal ine to the subject 's back

or forearm by the same operator.

Quintest (HS)

b puncture

Smal lpox needle

(HS) pr ick

DuoTip (L incoln) pr ick

Lancet (HS) puncture

Lancet (ALK) Puncture

DermaPICK I I (Biomedixs) Pr ick

0 mm

0 mm

1.5 mm

2 mm

3 mm

0 mm

DuoTip (L incoln)

twist

Bifurcated needle

(ALO) pr ick

Mult iTest(L incoln)

Puncture

Bifurcated needle

(ALO) puncture

Quick Test

(Pantrex)

Greer Track

(Greer)

3.5 mm

4 mm

4 mm

4.5 mm

4 mm

3.5 mm

Devices for which a 3-mm wheal would be significantDevices for which a wheal >3 mm should be used

as significant

Device99th Percentile of reactions at

the negative control sitesDevice

99th Percenti le of reactions

at the negative control sites

READING RESULTS

a) Oppenheimer J, Nelson HS. Skin Test ing. Ann Al l Asthma Immunol . 2006;96:S6-12.

b) HS = Hol l ister Steir, Greer = Greer laboratories , L incoln = Lincoln Diagnost ics , ALK = ALK America, ALO = Al lergy

Labs of Ohio"

Oppenheimer%20J,%20Nelson%20HS.%20Skin%20Testing.%20Ann%20All%20Asthma%20Immunol.%202006;96:S6-12.

HS%20=%20Hollister%20Steir,%20Greer%20=%20Greer%20laboratories,%20Lincoln%20=%20Lincoln%20Diagnostics,%20ALK%20=%20ALK%20America,%20ALO%20=%20Allergy%20Labs%20of%20Ohio%22

HS%20=%20Hollister%20Steir,%20Greer%20=%20Greer%20laboratories,%20Lincoln%20=%20Lincoln%20Diagnostics,%20ALK%20=%20ALK%20America,%20ALO%20=%20Allergy%20Labs%20of%20Ohio%22


The shots contain a smal l , but

increasing amount of the al lergen the

pat ient is sensit ive to. Whether given

in shot form or under the tongue,

immunotherapy involves giv ing

gradual ly increasing doses of the

substance to which the pat ient is

a l lergic (a lso known as the pat ient 's

a l lergen) .

That reduces the pat ient 's a l lergy

symptoms when the pat ient comes

across the al lergen in the future.

Immunotherapy also reduces the

inf lammation that comes with hay

fever and asthma.

THERAPY


Allergen immunotherapy, a lso known as al lergy shots , is a form of long-term treatment that

decreases symptoms for many people with al lergic rhinit is , a l lergic asthma, conjunct iv i t is (eye

al lergy) or st inging insect al lergy.

An al lergy shot decreases the sensit iv i ty to

al lergens, and of ten leads to last ing rel ief of

a l lergy symptoms even af ter treatment is

stopped. This makes i t a cost effect ive, benef ic ia l

treatment approach for many people.

IMMUNOTHERAPY PHASES

Immunotherapy treatment is structured to work

l ike a vaccine. Over t ime your body responds to

the injected amounts of an al lergen whi le

gradual ly increasing doses, by developing

immunity or tolerance to the al lergen.

Immunotherapy treatment decreases the

sensit iv i ty to al lergens and of ten leads to last ing

rel ief of a l lergy symptoms. Immunotherapy

treatment is broken down in 2 phases: bui ld-up and maintenance phase. Through these two phases

a pat ient can lower the chances of having an al lergic react ion.

BUILD-UP PHASE

During the bui ldup phase patients init ia l ly receive ver y low doses of al lergens by subcutaneous ( i .e .

into the t issue just under the skin) inject ion. With each shot , the dose is s lowly increased to bui ld

immune system tolerance. Af ter each shot , the pat ient is monitored for 30 minutes for any react ion.

The length of this phase depends upon how of ten the inject ions are received, but general ly ranges

from six to twelve months.

With a frequency of inject ions ranging from one to three t imes a week , that 's a Rx Dose of 52 – 156

for the f i rst year.

MAINTENANCE PHASE

The maintenance phase begins once the effect ive dose is reached. The effect ive maintenance dose

depends on the pat ient 's level of al lergen sensit iv i ty and the pat ient 's response to the bui ld-up

phase. During the maintenance phase, shots are spaced out to ever y 2-4 weeks or longer, as

prescr ibed by the provider. During this t ime the dose of al lergen remains constant . Typical ly, a

pat ient wi l lbe on Classic SCIT (subcutaneous immunotherapy) for 3-5 years .

ALLERGY IMMUNOTHERAPY


Immunotherapy treatment, a lthough effect ive is not for ever yone. There are cer tain restr ict ions to who

can and who cannot par t ic ipate in immunotherapy treatment. These pat ient 's i f they par t ic ipate in

immunotherapy are putt ing themselves at r isk for fur ther medical problems. In order to keep the pat ient

safe, we advise ever y pat ient check with their doctor f i rst before they par t ic ipate in immunotherapy.

PATIENTS ON BETA-BLOCKERS

For pat ients on beta blockers , combining epinephrine and beta-blocker medicat ion can be l i fe-

threatening to a pat ient . In the absence of a beta-blocker, a systemic dose of epinephrine does not have

much effect on the mean blood pressure because i t has both alphaadrenergic effects (producing

vasoconstr ict ion) and beta-adrenergic effects (producing vasodi lat ion) . I f a pat ient on a nonselect ive

beta-blocker receives a systemic dose of epinephrine the beta-blocker prevents the vasodi lat ion,

leaving unopposed alpha vasoconstr ict ion. The result ing hyper tensive react ion can be large enough to

possibly lead to a stroke in some patient 's shouldn't have an apostrophes. Your Jor tay provided medical

ass istant wi l l not administer al lergy immunotherapy treatment (al lergy shots) to a pat ient taking beta

blocker medicat ion

WHO SHOULD AND SHOULDN'T GET THERAPY


A color-coding system is used to identi fy the strength of pat ient treatment vials .

S i lver is the f i rst color, which is the weakest . The color-coding system then goes,

green, blue, yel low and red. Red is the highest concentrat ion possible . The red dose is

achieved in the maintenance phase of immunotherapy and is where the effect ive dose

is reached to treat the al lergen.

TREATMENT VIALS

COLOR CODE

SILVER

GREEN

BLUE

YELLOW

RED

STRENGTH

WEAKEST CONCENTRATION

1:10,000 vol/vol

1:1,000 vol/vol

1:100 vol/vol

1:10 vol/vol

1:1 vol/vol

DILUTION

STRONGESTCONCENTRATION

Bu

ild

-Up

Main

ten

an

ce


There are two reasons why a pat ient would need mult iple prescr ipt ions:

è Cer tain al lergens are recommended to not be mixed together ; therefore, i f a pat ient is to be treated

for al lergens that wi l l counteract each other, that could warrant mult iple prescr ipt ions.

è I t is recommended that no more than ten (10) al lergens be mixed together. I f the pat ient is to be

treated for more than 10 al lergens, this would also warrant mult iple prescr ipt ions." there are two

dif ferent reasons why the pat ient would need mult iple prescr ipt ions.

The f i rst reason why a pat ient would need mult iple perscrpt ions is because one is i f the pat ient is

a l lergic to mold, pol len, dust , and dandruff.

Mold cannot be mixed with other al lergens therefore the pat ient would have to be on mult iple

prescr ipt ions. Also, i f a pat ient is a l lergic to more than 10 al lergens then wi l l have mult iple

prescr ipt ions.

PRESCRIPTIONS


Allergy inject ions (shots) are most commonly used and the most effect ive

form of al lergy immunotherapy. Each inject ion contains a smal l amount of an

al lergen that tr iggers the pat ient 's specif ic a l lergic react ion. Each inject ion

contains enough al lergens to st imulate the pat ient 's immune system. As the

pat ients progresses through treatment protocol the doses of the inject ion

increases, which helps the pat ient 'sbody get use to the al lergens

(desensit izat ion) . Desensit izat ion is the el imination or reduction of natural or

acquired react iv i ty or sensit iv i ty to an external st imulus (al lergen) . Whi le

taking al lergy inject ions one wi l l become desensit ized to the al lergen and be

able to l ive l i fe symptom free.

Introduction

Allergy inject ions are NOT administered the same way that vaccines l ike f lu

shots or pediatr ic shot ser ies are given. Al lergy shots are given into the sub-

cutaneous t issues and NOT the muscle l ike most vaccines. The subcutaneous

t issue is the layer where the fat is…or the layer between the skin and muscle .

This document attempts to instruct how one administers al lergy shots

correct ly into the subcutaneous t issues. As with al l information provided by

Jor tay and the Taylor Al lergy program, al l pat ient treatment plans, dosage

and administrat ion is decided by the pat ient ’s physic ian.

THE WRONG WAY TO GIVE AN ALLERGY SHOT!

Note that the syringe was inserted incorrectly. The skin was not

pinched prior to insertion. Most likely, the needle is in the muscle

and there is an increased risk of anaphylaxis if given improperly

like this.

Please be mindful of word spacing and line breaks. As some of the

words are running together and there's an unnecessary line break.

How to Give Allergy

Shots

ALLERGY INJECTIONS

After drawing up the appropriate amount of allergy serum, hold the syringe

comfortably in your dominant hand. Visually confirm correct volume of serum drawn

up and that there are no air bubbles present.

Step 1:

The allergy shot is administered into the tricep region of the arm (back part of the

upper arm). Pinch only the skin (excluding the muscle) between your thumb and index

finger using your non-dominant hand. Pinching helps lift and isolate the

subcutaneous tissues up and away from the muscle.

Step 2:

Insert needle into the skin ONLY HALF THE LENGTH OF THE NEEDLE!!! Do NOT push

the needle all the way in. Inject the serum.

Step 3:


Missed treatment protocol happens when a pat ient is not taking their a l lergy inject ions on the

prescr ibed t ime frame. To get the pat ient back on track we have a missed inject ion protocol

system. When, a pat ient has not had their a l lergy inject ion in under 10 days they are f ine to

continue taking the same dose that they are currently prescr ibed. Once a pat ient has been

without al lergy shots over 10 days they stand the r isk of backtracking and fur ther their actual

treatment t ime.

By 10 – 14 days: Repeat the last dose

By 14 – 21 days: Decrease by one dose

By > 21 days: Decrease by 2 doses

By > 40 days: Restar t at f irst dose for that vial with vial testing

By > 60 days: Retest and create new vials

MISSED TREATMENT PROTOCOL


TREATMENT TRACKING


TO PATIENTS RECEIVING DESENSITIZATION INJECTIONS IN OUR OFFICE

The fol lowing guidel ines are ver y impor tant for the safe and effect ive administrat ion of al lergy

desensit izat ion treatment and should be fol lowed careful ly :

1 . Any inject ion can cause a react ion of ( increased) wheezing, hives , nasal congest ion, runny nose,

vomit ing or s ignif icantly increased shor tness of breath. I f this occurs as a result of an al lergy inject ion, i t

wi l l general ly occur within two hours of the inject ion. I f one of these react ions occurs , or i f you feel that

you have become i l l as a result of an al lergy inject ion, you must contact one of our doctors immediately.

This can be done by cal l ing any one of our off ices or our home. In addit ion, i f this occurs , you must see

one of the doctors before your next inject ion.

2. Any inject ion can cause a react ion of redness or swel l ing or pain on your arm where you receive the

inject ion. I f this occurs the day of the inject ion, i t is a normal react ion. I f i t lasts unti l the day af ter the

inject ion, this should be repor ted to one of the nurses pr ior to your next inject ion.

3. TO PATIENTS WITH HIGH BLOOD PRESSURE, GLAUCOMA OR HEADACHE: Please noti fy our off ice i f your

pr imar y care physic ian gives you a drug cal led a beta blocker for control of your high blood pressure,

glaucoma or headache.

4. IF YOU HAVE BEEN STARTED ON ANY NEW MEDICINE/DRUG SINCE YOUR LAST VISIT, PLEASE INFORM

THE NURSE OR DOCTOR BEFORE YOUR INJECTION.

5. I f you are feel ing wel l , you may receive your inject ions without wait ing to see the doctor. However, we

would l ike to have you see a doctor each t ime you star t new vials .

6 . I f you are having any symptoms or are s ick , please schedule an appointment to see your doctor before

receiving an inject ion.

7. To expedite your v is i t , please schedule with the receptionist the day you wish to come in for inject ion or

to see the doctor.

8 . You should wait in our off ice for 20 – 30 minutes af ter each inject ion in case there is a react ion to an

inject ion.

9. Optimum therapeutic results usual ly require three to f ive years of desensit izat ion therapy.

Discontinuation of therapy ear l ier than this may result in a higher increase of recurrence.

10. TO ALL OF OUR FEMALE PATIENTS: Not al l drugs used in treatment of al lergic diseases have been

cleared for use during pregnancy. I f you are planning on becoming pregnant , or are pregnant , please

discuss drug use with one of our physic ians.

11. Desensit izat ion therapy general ly takes at least 6-12 months before any benefit is noted.

Improvement thereaf ter may be gradual .

12. I f you have any quest ions regarding your inject ions, these instruct ions, or your al lergy symptoms,

please cal l our off ice at any t ime and speak with one of the doctors . There are 24 hour answering ser vices

on al l off ice and home telephones, and a physic ian is avai lable 24 hours a day for consultat ion.

13. Please inform your pr imar y physic ian of al lergy medicat ion you are taking, so proper prescr ibing can

occur

HOME THERAPY


GENERAL RELEASE

Patient ’s Name: __________________________________________________________ I have requested that al lergy

inject ions prescr ibed and/or provided by ________________________ be administered by someone other than

employees of the off ice. I acknowledge that I have been advised by the off ice that the inject ion of the al lergy

extract should be per formed by a qual i f ied person and not by the pat ient , or the parent of the pat ient . I

understand that because of the above, the off ice, i ts agents , successors and assigns, and al l other persons, f i rms

and corporat ions involved in the manufacture and prescr ipt ion of the extract , cannot assume responsibi l i ty for

the administrat ion of the extract , and any result ing consequences.Therefore, on behalf of myself, my heirs ,

executors , administrators and assigns, as wel l as any minor chi ldren for which I am act ing as parent and/or

guardian, I hereby demise, release and forever discharge ________________________________ and Jor tay and their

agents , successors and assigns of whatsoever kind of nature, ar is ing from and by reason of any and al l known and

unknown, foreseen and unforeseen bodi ly and personal injur ies , and the consequences thereof, result ing and

to result f rom the administrat ion of said al lergy extracts . I acknowledge that the person who wi l l be requested to

administer and inject the extract wi l l be advised of this release. I understand that the __________________________

advised against this and I have decided to waive that warning and continue home administrat ion. I understand

that the posit ion statement of the AAAAI strongly recommends against home administrat ion of al lergen

immunotherapy and I understand there have been deaths repor ted in associat ion with a l lergen

immunotherapy.

_______________________ _______ __________ _______________________________ _______ __________

Pat ient Signature Date Parent Signature ( for minor) Date

Address ___________________________________________________________________________________________________

___________________________________________________________________________________________________________

City, State, & Zip ___________________________________________________________________________________________


Anaphylaxis is a severe, potential ly

l i fe-threatening al lergic react ion. I t

can occur within seconds or

minutes of exposure to something

a pat ient is such as peanuts or bee

st ings.

Anaphylaxis causes a person's

release a f lood of chemicals that

can cause them to go into shock —

their blood pressure drops

suddenly, and your air ways narrow,

blocking breathing. Signs and

symptoms include a rapid, weak

pulse; a skin rash; and nausea and

vomit ing. Common tr iggers include

cer tain foods, some medicat ions,

insect venom and latex.

Anaphylaxis requires an inject ion

of epinephrine and a fol low-up tr ip

to an emergency room. I f there is

no epinephrine in the off ice, the

pat ient needs to go to an

emergency room immediately. I f

anaphylaxis isn't treated r ight

away, i t can be fatal .

ANAPHYLAXIS

Key Equipment and supplies to treat a patient when they have an anaphylactic episode.

Stethoscope Sphygmomanometer Injectable Epinephrine 1:1 ,000 or Epi Pensè � è � è

Oxygen Intravenous 0.9 normal (NL) sal ine 1-way valve facemaskè � è � è

Orophar yngeal and nasal phar yngeal a ir ways Disposable face masksè � è

Oxygen saturat ion monitor Albuterol inhalat ional solut ion (0 .05%), glucagonè � è

Written emergency protocol and char t for tracking patient treatmentè


Administer epinephrine intra-muscular ly in the mid-outer thigh. There is no absolute

contraindicat ion to the administrat ion of epinephrine as c lear ly stated in the Food and

Drug Administrat ion package inser t for AIE . This includes pat ients with acute coronar y

syndrome, and although the r isk-to-benefit rat io needs to be assessed with care in such

patient 's , i t usual ly favors the administrat ion of epinephrine.

Rapid administrat ion of a s ingle dose of epinephrine for mild symptoms of anaphylaxis

result ing from al lergy immunotherapy almost always stops the progression of symptoms,

with no addit ional epinephrine inject ions being required.

è Immediately assess air ways, breathing, c irculat ion, mentat ion and summon appropriate

assistance from staff members .

è I f needed, star t CPR and cal l 911 for EMS.

è In some patient 's , a second inject ion of epinephrine may be necessar y.

è Place pat ient in a supine posit ion, unless respirator y compromise contraindicates to

prevent or counteract potential c i rculator y col lapse.

è Pregnant pat ients should be on their lef t s ide. I f di f f iculty breathing, have patient s i t

up.

To maintain hemodynamic stabi l i ty, intravenous access is essential . Hypotension should be

treated with rapid f luid replacement using 1 to 2 L of 0 .9% normal sal ine, infused rapidly

(e .g. 5-10 mL/kg within the f i rst 5 minutes for an adult and up to 30 mL/kg in the f i rst hour

for chi ldren) .

Administrat ion of oxygen is the second most impor tant therapeutic inter vention, second

only to epinephrine administrat ion, and should be considered for al l pat ient 's regardless

of their respirator y status. Oxygen should be administered to pat ients with any respirator y

dif f iculty.

Oxygen up to 100% should be administered at a f low rate of 6 to 10 L/min through a

facemask . Ideal ly oxygen saturat ion should be monitored and kept at 94% to 96% by

oximetr y.

In most off ice sett ings, bag-valve-mask venti lat ion wi l l be the method of choice to suppor t

venti lat ion in the event of respirator y fai lure or arrest . When provider can adequately

venti late the pat ient using the bag-valve-mask , there is no evidence that the use of

MANAGEMENT OF ANAPHYLAXIS AT THE ONSET


MANAGEMENT OF ANAPHYLAXIS AT THE ONSET

For s igns and symptoms of

bronchospasm (e.g. wheezing,

coughing and shor tness of

breath) that has not responded

to intramuscluar epinephrine,

administer albuterol (adult dose

2.5 – 5.0 mg/3mL of sal ine;

pediatr ic dose 2.5 mg/3mL of

sal ine) through a nebul izer and

facemask .

I t is recommended that al l

Advanced Cardiovascular L i fe

Suppor t providers be trained

and experienced in the inser t ion

of 1 advanced air way because

there wi l l be t imes when the

bag-mask is inadequate.

Rapid administrat ion of a s ingle

dose of epinephrine for mild

symptoms of anaphylaxis

result ing from al lergy

immunotherapy (AIT) a lmost

always stops the progression of

symptoms, with no addit ional

epinephrine inject ions being

required.

In contrast , delayed

administrat ion of epinephrine is

of ten bel ieved to be the major

contr ibuting factor to fatal i t ies .


A treatment and act ion plan that is easy to read and fol low during an emergency.

I t should be posted in al l pat ient care areas of the off ice and with the emergency suppl ies

for ready access .

Maintain c l inical prof ic iency with anaphylaxis management involves cer t i f icat ion in basic

cardiopulmonar y resuscitat ion and, ideal ly, advanced l i fe suppor t to insure the proper

ski l lset for treatment of refractor y anaphylaxis , including air way management, cardiac

compressions, venous and intraosseous access , and parental medicat ion calculat ion and

del iver y.

Immediate Measures:

è Air way: Assess air way, breathing, c irculat ion, and orientat ion; i f needed, suppor t the

air way using the least invasive but effect ive method (e .g. bag-valve-mask) .

è CPR: Star t chest compressions (100/min) i f cardiovascular arrest occurs at any t ime.

è Epinephrine intramuscular : Inject epinephrine 0.3-0.5mg (0.01 mg/kg for chi ldren)

intramuscular ly in the vastus lateral is ( lateral thigh) .

è Get Help: Summon appropriate assistance in off ice.

è Posit ion: Place adults and adolescents in recumbent posit ion; place young chi ldren in

posit ion of comfor t ; place pregnant pat ient on lef t s ide.

è Oxygen: Give 8-10 L/min through facemask or up to 100% oxygen as needed; monitor

by pulse oximetr y i f avai lable.

è Epinephrine intramuscular : Repeat epinephrine ever y :15 minutes for up to 3 inject ions

i f the pat ient is not responding.

è EMS: Cal l 911 i f no immediate response to f i rst dose of intamuscular epinephrine or i f

anaphylaxis is moderate to severe.

è Intravenous f luids : Establ ish intravenous l ine for venous access and f luid replacement;

keep open with 0.9 NL sal ine, push f luids for hypotension or fai lure to respond to

epinephrine using 5-10mg/kg as quickly as possible and up to 30 mL/kg in f i rst hour for

chi ldren and 1-2L for adults .

OFFICE-BASED ANAPHYLAXIS ACTION PLAN


Additional treatment measures

Albuterol : Consider administrat ion of 2 .5 – 5mg of nebul ized albuterol in 3 mL of sal ine

for lower air way obstruct ion; repeat necessar y ever y 15 min.

Glucagon: Pat ient 's on beta blockers who are not responding to epinephrine should be

given 1 – 5 mg of glucagon intravenously s lowly over 5 min because rapid administrat ion

of glucagon can induce vomit ing.

Advanced air way management: Use supraglott ic air way, endotracheal intubation, or

cr icothyroidotomy for marked str idor, severe lar yngeal edema, or when venti lat ions using

the bag-valve-mask is inadequate and EMS has not arr ived.

Optional treatment (eff icacy has not establ ished)

H1 antihistamine: Consider giv ing 25– 50mg of diphenhydramine intravenously for adults

and 1 mg/kg (maximum of 50 mg) for chi ldren; use to 10mg of cet ir iz ine i f an oral

ant ihistamine is administered.

Cor t icoster iods: Administer 1 -2 mg/kg up to 125 mg per does, intravenously or oral ly, of

methyplprednisolne or an equivalent formulat ion.

Obser vation and monitoring

Obser vat ion in the off ice: Obser ve in off ice unti l ful l recover y for an addit ional 30-60

minutes for al l pat ients who are not candidates for EMS transpor t to hospital .

Discharge Management

Education: Educate pat ient and family on how to recognize and how to treat anaphylaxis

Auto-injectable epinephrine: Prescr ibe two (2) doses of auto-injectable epinephrine for

pat ients who have experienced an anaphylact ic react ion and for those at r isk for severe

anaphylaxis ; train pat ient , pat ient provider, and on family on how to use auto-injector.

Anaphylaxis act ion plan: Provide patients with an act ion plan instruct ing them on how and

when to administer epinephrine.

OFFICE-BASED ANAPHYLAXIS ACTION PLAN


Food al lergies is an immune system react ion that occurs soon af ter eat ing a cer tain food. Even a

t iny amount of the al lergy-causing food can tr igger s igns and symptoms such as digest ive

problems, hives , or swol len air ways. In some people, a food al lergy can cause severe symptoms

or even a l i fe-threatening react ion known as anaphylaxis .

For some people, an al lergic react ion to a food may be uncomfor table but not severe. For other

people, an al lergic food react ion can be fr ightening and even l i fe-threatening. Food al lergy

symptoms usual ly develop within a few minutes to two hours af ter eat ing the offending food.

The most common food allergy signs and symptoms include:

è Tingl ing or i tching in the mouth

è Hives, i tching or eczema

è Swel l ing of the l ips , face, tongue and throat or other par ts of the body

è Wheezing, nasal congest ion or trouble breathing

è Abdominal pain, diarrhea, nausea or vomit ing

è Dizziness , l ightheadedness or fa int ing

When it comes to food al lergy test ing there are three methods that are used most frequently to

test the accuracy of a pat ient 's a l lergies to food. Those tests consist of the IgE test , the IgG test

and the Alcat test .

FOOD ALLERGY TESTING


Allergies are a common and chronic condit ion that involves the body 's immune system.

Normal ly, a person's f ight off v iruses, bacter ia , and other infect ious agents . When a person has

an al lergy, their system treats a harmless substance, l ike dust or pol len, as a threat . To f ight

this perceived threat , their immune system makes antibodies cal led immunoglobul in E ( IgE) .

These antibodies travel to cel ls that release chemicals , causing an al lergic react ion. This

react ion usual ly causes symptoms in the nose, lungs, throat , or on the skin.

IgE Testing


IgG Testing

Immunoglobul in G ( IgG) , the most abundant types

of ant ibodies , is found in al l body f luids and

protects against bacter ia l and viral infect ions.

Immunogobul in G ( IgG) tests measure delayed

immune react ions of foreign objects or undigested

proteins that leak across the gut l in ing and into

the blood stream causing a delayed immune

response.

In IgG test ing, the blood is tested for IgG antibodies instead of being tested for IgE antibodies

( i .e . , the antibodies typical ly associated with food al lergies) . The existence of serum IgG

antibodies towards foods is c la imed by many pract i t ioners as a tool to diagnose food al lergy

or intolerance.


The Alcat test measures food and immune react ions through st imulat ion of leukocytes .

The leukocytes , which comprise f ive c lasses of white blood cel ls , including monocytes,

lymphocytes, eosinophi ls , basophi ls and neutrophi ls (~ 70 - 80% of WBC's) can be

chal lenged with individual food or chemical extracts . Immunologic defense react ions, of

neutrophi ls , in it iate an instrumental pr imar y role in inf lammation. Whi le this is a ver y

effect ive f i rst- l ine defense strategy against acute infect ions, chronic act ivat ion of the

immune system may lead to health disorders .

The Alcat Test does not identi fy type 1 c lassical IgE mediated (anaphylaxis) a l lergies .

The dif ference between the Alcat Test and IgG antibody test ing: Food and Chemical

sensit iv i t ies are mediated by mult iple pathogenic mechanisms. By using the cel lular

approach, instead of a s ingle antibody such as IgG, the Alcat Test can identi fy food and

chemical sensit iv i t ies regardless of the pathway ( immunologic , toxic , pharmacologic) . The

cel ls release free radicals and inf lammator y mediators without antibody involvement.

Most studies suggest that food specif ic IgG antibodies are protect ive and thereby not

pathogenic .

ALCAT


The Alcat Test gives healthcare professionals a tool for managing condit ions l inked to

inf lammation and chronic act ivat ion of the immune system. The Alcat Test measures

individual responses to foods and other substances on the cel lular level and may

reveal the underly ing tr igger of cer tain symptoms.

Food and chemical sensitivit ies have been l inked to migraines, aching joints,

fatigue, gastrointestinal disorders, and other symptoms related to chronic

activation of the immune system.

Clinical assessments of the Alcat Test used to guide dietar y modif icat ion have shown

signif icant improvement in many common symptoms. The eff icacy of the Alcat Test has

been documented in numerous studies implementing r igorous double-bl ind and of ten

placebo-control led study designs.


FORMS

_____________________

Medical Assistant

Patient Name: __________________________________________________________________________________

Date: _____________________

D.O.B.: ___________________

S

ER

VIC

E F

OR

M

95004 Allergy Testing ___________________

95115 Single Injection

95117

Multiple Injections

95165

Immunotherapy ______________ Doses X

___________#of Prescription

DX Code (s):

Primary Insurance: __________________________________________________________________________

Secondary Insurance: _______________________________________________________________________

Tertiary Insurance: __________________________________________________________________________

The above insurance policy is current and I attest I have no other insurance for th is

date of service.

NOTE: While allergy testing and treatment (immunotherapy) are usually a

covered expense by insurance companies, copays and deductibles may still apply.

___________________________________

Patient’s Signature

Date

______________________________

Internal Use:

________________________

________________________

Practice Name/Ordering Physician: Telephone: ( ) -

Street Address: Fax: ( ) -

City: State Zip Email:

Controls: Epicutaneous: NEGATIVE: POSITIVE: Intradermal: POSITIVE:

Epicutaneous: Testing Date(s): / / Testing Time: AM PM

Intradermal: Testing Date(s): / / Testing Time: AM PM

Practitioner Signature Date

PANEL B Epicutaneous

W (mm) F

Intradermal

W (mm) FSite Allergen

1

2

3

4

5

PANEL A Epicutaneous

W (mm) F

Intradermal


1

2

3

4

5

PANEL A Epicutaneous

W (mm) F

Intradermal

W (mm) F

Site Allergen

PANEL B Epicutaneous

W (mm) F

Intradermal

W (mm) F

Site Allergen

6

7

8

9

10

PANEL C Epicutaneous

W (mm) F

Intradermal


1

2

3

4

5

PANEL C Epicutaneous

W (mm) F

Intradermal

W (mm) F Site Allergen

6

7

8

9

10

PANEL D Epicutaneous

W (mm) F

Intradermal


1

2

3

4

5

PANEL D Epicutaneous

W (mm) F

Intradermal

W (mm) F

Site Allergen

6

7

8

9

10

PANEL E Epicutaneous

W (mm) F

Intradermal


1

2

3

4

5

PANEL E Epicutaneous

W (mm) F

Intradermal

W (mm) F

Site Allergen

6

7

8

9

10

PANEL F Epicutaneous

W (mm) F

Intradermal


1

2

3

4

5

PANEL F Epicutaneous

W (mm) F

Intradermal

W (mm) F

Site Allergen

6

7

8

9

10

6

7

8

9

10

Patient Name: Patient ID:

Date of Birth: / /

Days: Medication:

Days: Medication:

Location: Back: q

Arm: q

Testing Technician:

NEGATIVE:

Last use of antihistamin e(o r othe rmedicatio naectin g respon se to histamine


PA

NE

L T

ES

TIN

G S

HE

ET

ALLERGEN IMMUNOTHERAPY PATIENT CONSENT FORM

Immunotherapy, hyposensit izat ion, or al lergy inject ions should be administered at a medical

faci l i ty with a medical physic ian present s ince occasional react ions may require immediate therapy.

These react ions may consist of any or a l l the fol lowing symptoms: i tchy eyes, nose, or throat ; nasal

congest ion; runny nose; t ightness in the throat or chest ; coughing; increased wheezing;

l ightheadedness; fa intness ; nausea and vomit ing; hives ; general ized i tching; and shock , the last

under extreme condit ions. React ions, even though unusual , can be ser ious and

rarely, fatal . You are required to wait in the medical faci l i ty in which you receive the inject ions for 30

minutes af ter each inject ion. I f the pat ient is 17 years of age or younger, a parent or legal guardian

must be present during the wait ing period. I ver i fy that I (or pat ient) am not taking betablocker

medicat ions or that i f I am, I have discussed the r isks/benefits of doing so with my physic ian (see

information sheet) .

I have read ( i f new patient) or re-read ( i f establ ished patient) the pat ient information sheet on

immunotherapy and understand it . The oppor tunity has been provided for me to ask quest ions

regarding the potential s ide effects of immunotherapy and these quest ions have been answered to

my sat isfact ion. I understand that ever y precaution consistent with the best medical pract ice wi l l

be carr ied out to protect me against such react ions. I a lso agree that i f I have an al lergic react ion to the

inject ions that the physic ian-in-charge has permission to treat said react ion.

I acknowledge the fact with my s ignature that I am authoriz ing the off ice to bi l l for al lergen vaccines,

even i f, for any reason, I decide not to init iate the al lergen immunotherapy program af ter the vaccine

has been made. Vaccines may be prepared up to 12 weeks pr ior to my appointment. I agree to obtain

pr ior authorizat ion, i f needed, from my insurance plan.Pat ient is ult imately responsible for any

charges incurred in this off ice.

I t is your legal responsibi l i ty to pay any deductible amount, co-payments , co-insurance, and or any

other balances not paid by your insurance carr ier or supplemental insurance. Your s ignature on this

document indicates that you agree to pay for any outstanding charges incurred in this off ice.

Pat ient Name: __________________________________________________________________________

Patient Signature:__________________________________________ DATE ______________________

PARENT or LEGAL GUARDIAN_____________________________ DATE ________________________

As parent or legal guardian, I understand that I must accompany my chi ld throughout

the entire 30-minute wait .

WITNESS__________________________________________________ DATE________________________



BL

AN

K P

ER

SC

RP

TIO

N

Maintenance Concentrate

Prescription Form

Patient Name:

Patient Number:

Birthdate:

Telephone:

Prescribing Physician:

Address:

Telephone:

Fax:

Allergen Extract Content:

*Components of mixes listed on a separate

sheet Specific Instructions:

Prepared by: Date prepared:

Volume to add =Maintenance Concentration

Conc. of Manufacturer’s Extractx Total Volume

Bottle Name AbbreviationsTree: T Mold:MGrass: G Cat: CWeed: W Dog: DRagweed: R Cockroach: CrMixture: Mx Dust Mite: Dm

AntigenNumber

Extract Name Allergen or Di-luent (Common

Phrase orGenus

species)*

Concentration and Type of

Manufacturer’s Extract (AU, BAU, W/V,

PNU)/(50% G, Aq, Ly, AP, AL)

Volume of Manufacturer’s Extract to Add

Extract Manu-facturer

Lot Number Expiration Date

1

2

3

4

5

6

7

8

9

10

Diluent

TotalVolume

BAU = Bioequivalent Allergy Unit, AU = Allergy UnitPNU = Protein Nitrogen UnitW/V = Weight per Volume RationG = 50% GlycerinatedAq = Aqueous, Ly = LyophilizedA::= Alum precipitated, AP = Acetone precipitated

Maintenance concentration and subsequent dilutions reported as volume/volume (v/v) dilutions with mainte-

/

concentration=1:1 v/vnance

/

AL

LE

RG

Y &

IM

MU

NO

TH

ER

AP

Y N

OT

ES

D.O.S .: ___________________

Patient Name: ____________________________

D.O.B.: ________________________

Plan

Allergen Test

Allergen Skin

Test Results & Recommendations

Procedure Codes:

95004: ____________________________

# Extracts/Allergens Tested

95165: ______________________________

#D oses Prescribed

Provider Name: ______________________________________________________

Provider Signature: __________________________________________________



ALLERGY IMMUNOTHERAPY PRESCRIPTION

Physic ian’s Name: _______________________________________________ DEA# ____________________________

Tax ID #: _________________________________________ NPI#:____________________________________________

Patient ’s Ful l Name: _______________________________________________________ D.O.B. : _________________

Insurance Carr ier : _________________________________________ Phone No: _____________________________

Preferred Pharmacy: _______________________________________________________________________________

CHECK NEEDED PRESCRIPTION:

OTC/LIQUID 12.5 MG/5ML Chi ldren’s Benadr yl (Diphenhydramine) Use as directed by provider for

any mild al lergic react ions.

CHECK ONE ONLY:

ADULT EPI-PEN 1 Pak Epinephrine Auto-Injectors .3MG

For a weight of 66 pounds or more. Keep with you when administer ing Immunotherapy as directed

by provider. Should only be used in the event of a severe al lergic react ion. (No Ref i l ls ) .

EPI-PEN Jr. 1-Pak Epinephrine Auto-Injectors .15MG

For Chi ldren weighing between 33 – 65 pounds. Keep with you when administer ing immunotherapy

as directed by provider. Should only be used in the event of a severe al lergic react ion. (No Ref i l ls ) .

Physic ian’s Signature: ______________________________________ Date: _____________________


Skin Test: Skin tests are methods of test ing for al lergic ant ibodies . A test consists of

introducing smal l amounts of the suspected substance, or al lergen, into the skin and noting

the development of a posit ive react ion (which consists of a wheal , swel l ing, or f lare in the

surrounding area of redness) . The results are read at 15 to 20 minutes af ter the appl icat ion

of the al lergen. The skin test methods are:

Prick Method: The skin is pr icked with a needle where a drop of al lergen has already been

placed.

Intradermal Method: This method consists of inject ing smal l amounts of an al lergen into

the super f ic ia l layers of the skin.

Interpret ing the cl inical s ignif icance of skin tests requires ski l l ful correlat ion of the test

results with the pat ient ’s c l inical histor y. Posit ive tests indicate the presence of al lergic

ant ibodies and are not necessar i ly correlated with c l inical symptoms.

You wi l l be tested to impor tant ( locat ion) airborne al lergens and possibly some foods.These

include, trees, grasses, weeds, molds, dust mites , and animal danders and, possibly some

foods. The skin test ing general ly takes 45 minutes. Pr ick (also known as percutaneous) tests

are usual ly per formed on your back but may also be per formed on your arms. Intradermal

skin tests may be per formed i f the pr ick skin tests are negative and are per formed on your

arms. I f you have a specif ic a l lergic sensit iv i ty to one of the al lergens, a red, raised, i tchy

bump (caused by histamine release into the skin) wi l l appear on your skin within 15 to 20

minutes. These posit ive react ions wi l l gradual ly disappear over a period of 30 to 60

minutes, and, typical ly, no treatment is necessar y for this i tchiness . Occasional ly local

swel l ing at a test s i te wi l l begin 4 to 8 hours af ter the skin tests are appl ied, par t icular ly at

s i tes of intradermal test ing. These react ions are not ser ious and wi l l disappear over the

next week or so. They should be measured and repor ted to your physic ian at your next v is i t .

You may be scheduled for skin test ing to antibiot ics , caines, venoms, or other biological

agents . The same guidel ines apply.

DO NOT

1. No prescr ipt ion or over the counter oral ant ihistamines should be used 4 to 5 days pr ior

to scheduled skin test ing. These include cold tablets , s inus tablets , hay fever medicat ions,

or oral treatments for i tchy skin, over the counter al lergy medicat ions, such as Clar i t in ,

Zyr tec, Al legra, Act i fed, Dimetapp, Benedr yl , and many others .Prescr ipt ion antihistamines

such as Clar inex and Xyzol should also be stopped at least 5 days pr ior to test ing. I f you

have any quest ions whether or not you are using an antihistamine, lease please asks the

nurse or the doctor. In some instances a longer period of t ime off these medicat ions may be

necessar y.

PATIENT INSTRUCTION/CONSENT FORM FOR ALLERGY SKIN TESTING


2. You should discontinue your nasal and eye antihistamine medicat ions, such as Patanase,

Pataday, Astepro, Optivar, or Astel in at least 2 days before the test ing. In some instances a

longer period of t ime off these medicat ions may be necessar y. I f you have any quest ions

whether or not you are using an antihistamine, lease please asks the nurse or the doctor. In

some instances a longer period of t ime off these medicat ions may be necessar y.

3 . Medicat ions such as over the counter s leeping medicat ions (e .g. Tylenol PM) and other

prescr ibed drugs, such as amytr iptyl ine hydrochlor ide (Elavi l ) , hydroxyzine (Atarax) ,

doxepin (Sinequan) , and imipramine (Tofrani l ) have antihistaminic act iv i ty and should be

discontinued at least 2 weeks pr ior to receiving skin test af ter consultat ion with your

physic ian. Please make the doctor or nurse aware of the fact that you are taking these

medicat ions so that you may be advised as to how long prior to test ing you should stop

taking them.

YOU MAY

1. You may continue to use your intranasal a l lergy sprays such as Flonase Rhinocor t ,

Nasonex, Nasacor t . Omnaris , Veramyst and Nasarel .

2 . Asthma inhalers ( inhaled steroids and bronchodi lators) , leukotr iene antagonist s (e .g.

Singulair, Accolate) and oral theophyl l ine (Theo-Dur,T-Phyl , Uniphyl , Theo-24, etc . ) do

not inter fere with skin test ing and should be used as prescr ibed.

3. Most drugs do not inter fere with skin test ing but make cer tain that your physic ian and

nurse know about ever y drug you are taking (br ing a l ist i f necessar y) . .

Skin test ing wi l l be administered at this medical faci l i ty with a medical physic ian or other

health care professional present s ince occasional react ions may require immediate therapy.

These react ions may consist of any or al l of the fol lowing symptoms: i tchy eyes, nose, or

throat ; nasal congest ion; runny nose; t ightness in the throat or chest ; increased wheezing;

l ightheadedness; fa intness ; nausea and vomit ing; hives ; general ized i tching; and shock , the

latter under extreme circumstances. Please let the physic ian and nurse know i f you are

pregnant or taking beta blockers . Al lergy skin test ing may be postponed unti l af ter the

pregnancy in the unl ikely event of a react ions to the al lergy test ing and beta-blockers are

medicat ions they may make the treatment of the react ion to skin test ing more dif f icult .

Please note that these reactions rarely occur but in the event a reaction would occur,

the staff is ful ly trained and emergency equipment is available.

After skin test ing, you wi l l consult with your physic ian or other health care professional who

wi l l make fur ther recommendations regarding your treatment.

We request that you do not br ing smal l chi ldren with you when you are scheduled for skin

test ing unless they are accompanied by another adult who can s it with them in the

reception room.


___________________________________________________________________________________________

I have read the pat ient information sheet on al lergy skin test ing and understand it . The

oppor tunity has been provided for me to ask quest ions regarding the potential s ide effects

of al lergy skin test ing and these quest ions have been answered to my sat isfact ion. I

understand that ever y precaution consistent with the best medical pract ice wi l l be carr ied

out to protect me against such react ions.

Pat ient is ult imately responsible for any charges incurred in this off ice. I t is your legal

responsibi l i ty to pay any deductible amount, co-payments , co-insurance, and or any other

balances not paid by your insurance carr ier or supplemental insurance. Your s ignature on

this document indicates that you agree to pay for any outstanding charges incurred in this

off ice.

Pat ient Name: ______________________________________________________________________________

Patient Signature___________________________________________ Date s igned___________________

Parent or legal guardian*__________________________________ Date s igned____________________

*as parent or legal guardian, I understand that I must accompany my chi ld throughout the

entire procedure and vis i t .

Witness ____________________________________________________ Date s igned___________________


ALLERGY

Allergies are inappropriate or exaggerated react ions of the immune system to substances that , in the

majority of people, cause no symptoms. Symptoms of the al lergic diseases may be caused by

exposure of the skin to a chemical , of the respirator y system to par t ic les of dust or pol len (or other

substances) , or of the stomach and intest ines to a par t icular food.

ANAPHYLAXIS

Anaphylaxis , or anaphylact ic shock , is a severe, f r ightening and l i fe-threatening al lergic react ion. The

react ion, a lthough rare, can occur af ter an insect st ing or as a react ion to an injected drug - for

example, penici l l in or ant itetanus (horse) serum. Less commonly, the react ion occurs af ter a

par t icular food or drug has been taken by mouth.

ANTIBODY

An antibody is a protein (also cal led an immunoglobul in) that is manufactured by lymphocytes (a type

of white blood cel l ) to neutral ize an antigen or foreign protein. Bacter ia , v i ruses and other

microorganisms commonly contain many antigens, as do pol lens, dust mites , molds, foods, and other

substances. Although many types of ant ibodies are protect ive, inappropriate or excessive formation

of ant ibodies may lead to i l lness . When the body forms a type of ant ibody cal led IgE ( immunoglobul in

E) , a l lergic rhinit is , asthma or eczema may result when the pat ient is again exposed to the substance

which caused IgE antibody formation (al lergen) .

ANTIGEN

An antigen is a substance that can tr igger an immune response, result ing in production of an

antibody as par t of the body 's defense against infect ion and disease. Many antigens are foreign

proteins (those not found natural ly in the body) . An al lergen is a special type of ant igen which causes

an IgE antibody response.

ANTIHISTAMINE DRUGS

Antihistamines are a group of drugs that block the effects of histamine, a chemical released in body

f luids during an al lergic react ion. In rhinit is , ant ihistamines reduce i tching, sneezing, and runny nose.

ANTI-INFLAMMATORY DRUGS

Anti- inf lammator y drugs reduce the symptoms and s igns of inf lammation. Although not a drug,

immunotherapy ("al lergy shots") reduces inf lammation in both al lergic rhinit is and al lergic asthma.

ASTHMA

Asthma is a chronic , inf lammator y lung disease character ized by recurrent breathing problems.

People with asthma have acute episodes or when the air passages in their lungs get narrower, and

breathing becomes more dif f icult . Sometimes episodes of asthma are tr iggered by al lergens,

a lthough infect ion, exercise, cold air and other factors are also impor tant tr iggers .

RESOURCES


BRONCHITIS

Bronchit is is an inf lammation of the bronchi ( lung air ways) , result ing in persistent cough that

produces considerat ion quantit ies of sputum (phlegm). Bronchit is is more common in smokers and in

areas with high atmospheric pol lut ion.

BRONCHODILATOR DRUGS

Bronchodi lators are a group of drugs that widen the air ways in the lungs.

BRONCHUS

Any of the larger air passages that connect the trachea (windpipe) to the lungs. The plural form of

"bronchus" as "bronchi ."

CONTACT DERMATITIS

Contact dermatit is is an inf lammation of the skin or a rash caused by contact with var ious substances

of a chemical , animal or vegetable nature. The react ion may be an immunologic response or a direct

toxic effect of the substance. Among the more common causes of a contact dermatit is react ion are

detergents lef t on washed clothes, nickel ( in watch straps, bracelets and necklaces, and the

fastenings on underclothes) , chemicals in rubber gloves and condoms, cer tain cosmetics , plants such

as poison ivy, and topical medicat ions.

CORTICOSTEROID DRUGS

Cor t icosteroids are a group of ant i- inf lammator y drugs s imi lar to the natural cor t icosteroid

hormones produced by the cor tex of the adrenal glands. Among the disorders that of ten improve

with cor t icosteroid treatment include asthma, al lergic rhinit is , eczema and rheumatoid ar thr it is .

DIGESTIVE SYSTEM

The digest ive system is the group of organs that breaks down food into chemical components that

the body can absorb and use for energy and for bui lding and repair ing cel ls and t issues.

ECZEMA

An inf lammation of the skin, usual ly causing i tching and sometimes accompanied by crust ing, scal ing

or bl isters . A type of eczema of ten made worse by al lergen exposure is termed "atopic dermatit is" .

EPINEPHRINE

Epinephrine is a natural ly occurr ing hormone, also cal led adrenal ine. I t is one of two chemicals ( the

other is norepinephrine) released by the adrenal gland. Epinephrine increases the speed and force of

hear t beats and thereby the work that can be done by the hear t . I t di lates the air ways to improve

breathing and narrows blood vessels in the skin and intest ine so that an increased f low of blood

reaches the muscles and al lows them to cope with the demands of exercise. Epinephrine has been

produced synthetical ly as a drug s ince 1900. I t remains the drug of choice for treatment of

anaphylaxis .

EXTRINSIC ASTHMA

Extr insic asthma is asthma that is tr iggered by an al lergic react ion, usual ly something that is inhaled.


HAY FEVER

See Rhinit is .

HISTAMINE

Histamine is a chemical present in cel ls throughout the body that is released during an al lergic

react ion. Histamine is one of the substances responsible for the symptoms on inf lammation and is

the major reason for running of the nose, sneezing, and itching in al lergic rhinit is . I t a lso st imulates

production of acid by the stomach and narrows the bronchi or air ways in the lungs.

HIVES

See Ur t icar ia .

IMMUNE SYSTEM

The immune system is a col lect ion of cel ls and proteins that works to protect the body from

potential ly harmful , infect ious microorganisms (microscopic l i fe-forms) , such as bacter ia , v i ruses

and fungi . The immune system plays a role in the control of cancer and other diseases, but also is the

culpr it in the phenomena of al lergies , hypersensit iv i ty and the reject ion of transplanted organs,

t issues and medical implants .

IMMUNOGLOBULINS

Immunoglobul ins , a lso known as antibodies , are proteins found in blood and in t issue f luids .

Immunoglobul ins are produced by cel ls of the immune system cal led B-lymphocytes. Their funct ion

is to bind to substances in the body that are recognized as foreign antigens (of ten proteins on the

sur face of bacter ia and viruses) . This binding is a crucial event in the destruct ion of the

microorganisms that bear the antigens. Immunoglobul ins also play a central role in al lergies when

they bind to antigens that are not necessar i ly a threat to health and provoke an inf lammator y

react ion.

IMMUNOTHERAPY

Immunotherapy ("al lergy shots") is a form of preventive and anti- inf lammator y treatment of al lergy

to substances such as pol lens, house dust mites , fungi , and st inging insect venom. Immunotherapy

involves giv ing gradual ly increasing doses of the substance, or al lergen, to which the person is

a l lergic . The incremental increases of the al lergen cause the immune system to become less sensit ive

to the substance, perhaps by causing production of a par t icular "blocking" antibody, which reduces

the symptoms of al lergy when the substances is encountered in the future.

INFLAMMATION

Inf lammation is the redness, swel l ing, heat and pain in a t issue due to chemical or physical injur y, or

to infect ion. I t is a character ist ic of al lergic react ions in the nose, lungs, and skin.

INTRINSIC ASTHMA

Intr insic asthma is asthma that has no apparent external cause.

LYMPHOCYTE

A lymphocyte is any of a group of white blood cel ls of crucial impor tance to the adaptive par t of the


body's immune system. The adaptive por t ion of the immune system mounts a tai lor-made defense

when dangerous invading organisms penetrate the body 's general defenses.

MAST CELL

Mast cel ls play an impor tant role in the body 's al lergic response. Mast cel ls are present in most body

t issues, but are par t icular ly numerous in connective t issue, such as the dermis ( innermost layer) of

skin. In an al lergic response, an al lergen st imulates the release of ant ibodies , which attach

themselves to mast cel ls . Fol lowing subsequent al lergen exposure, the mast cel ls release substances

such as histamine (a chemical responsible for al lergic symptoms) into the t issue.

RAST

RAST is an abbreviat ion for RadioAl lergoSorbent Test , a trademark of Pharmacia Diagnost ics , which

or iginated the test . RAST is a laborator y test used to detect IgE antibodies to specif ic a l lergens.

RESPIRATORY SYSTEM

The respirator y system is the group of organs responsible for carr ying oxygen from the air to the

bloodstream and for expel l ing the waste product carbon dioxide.

RHINITIS

Rhinit is is an inf lammation of the mucous membrane that l ines the nose, of ten due to an al lergy to

pol len, dust or other airborne substances. Seasonal al lergic rhinit is a lso is known as "hay fever," a

disorder which causes sneezing, i tching, a runny nose and nasal congest ion.

SINUS

The s inuses (paranasal s inuses) are air cavit ies within the facial bones. They are l ined by mucous

membranes s imi lar to those in other par ts of the air ways.

SINUSITIS

Sinusit is is inf lammation of the membrane l ining the facial s inuses, of ten caused by bacter ia l or v iral

infect ion.

THEOPHYLLINE

Theophyl l ine is a bronchodi lator drug, given by mouth, that widens the air ways to the lung. I t a lso is

used to prevent attacks of apnea (cessat ion of breathing) in premature infants and to treat hear t

fa i lure because i t st imulates hear t rate and increases ur ine excret ion.

URTICARIA

Urticar ia is a skin condit ion, common known as hives , character ized by the development of i tchy,

raised white lumps surrounded by an area of red inf lammation.

The Role of Immunotherapy in the Treatment of Asthma

AHRQ Comparat ive Effect iveness Reviews, No. 196

Invest igators : Sandra Y Lin, M.D. , Antoine Azar, M.D. , Catal ina Suarez-Cuer vo, M.D. , Gregor y B.

Diette , M.D. , MHS, Emily Br igham, M.D. , Jessica Rice, D.O. , MHS, Murugappan Ramanathan, Jr. , M.D. ,

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No. : 13-EHC061-EF.

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SR Durham, SM Walker, EM Varga… - … England Journal of …, 1999 - Mass Medical Soc

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Vir tanen T.

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Mener DJ, L in SY.

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1781.2016.07.009. Chinese.

PMID:29871065

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Ridolo E , Rogkakou A , Ventura MT, Mar t ignago I , Incor vaia C, Di Lorenzo G, Passalacqua G.

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Al lergy and Asthma: Asthma Management.

Falk N.

FP Essent . 2018 Sep;472:25-29.

PMID:30152671


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Clark J, White ND.

Am J L i festyle Med. 2017 Apr 7;11(4) :310-313. doi : 10.1177/1559827617701389. eCol lect ion 2017

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Sánchez J, Cardona R, Sánchez A.

Rev Alerg Mex. 2016 Apr-Jun;63(2) :113-22. Spanish.

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Kl imek L , Chaker AM, Mösges R.

HNO. 2017 Oct ;65(10) :801-810. doi : 10.1007/s00106-017-0410-4. Review. German.

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Marchal O, Al la l i D.

Rev Med Suisse. 2018 Apr 4;14(601) :731-734. French.

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Sánchez J, Sánchez A , Cardona R.

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Næraa SH, Schol ler t NH, F lader Skov PN, Homøe P.

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Sohn MH.

Al lergy Asthma Immunol Res. 2018 Jan;10(1) :1-3. doi : 10.4168/aair.2018.10.1.1 . No abstract

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Vol lbracht C, Raithel M, Kr ick B, Kraf t K , Hagel AF.

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Lee J, McDonald C.

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Salvadé I , Moi L , Ribi C, Sper t ini F.

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Sánchez J, Sánchez A , Cardona R.

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Amat F, Sese L , Hayat M, Bourgoin-Heck M, Just J.

Ann Al lergy Asthma Immunol . 2018 Aug;121(2) :258-259. doi : 10.1016/j .anai .2018.05.021. Epub 2018

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PMID:29803710

The status of subl ingual immunotherapy in the treatment of al lergic diseases.

Okubo K , Izuhara K.

Al lergol Int . 2018 Jul ;67(3) :299-300. doi : 10.1016/j .a l i t .2018.06.001. No abstract avai lable.

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Immunotherapy, asthma and community al lergic react ions to food.

Rober ts G.

Cl in Exp Al lergy. 2016 Jun;46(6) :780-1. doi : 10.1111/cea.12752. No abstract avai lable.

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Burrows SH, Akinbobuyi O, Rule S , Crosbie N.

Br J Haematol . 2018 Jun;181(6) :836-837. doi : 10.1111/bjh.14703. Epub 2017 May 25. No abstract

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Grieco T, Paol ino G, Faina V, Mol iterni E , Carnicel l i G, Bottoni U, Calvier i S .


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Romero D.

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w w w . j o r t a y a l l e r g y . c o m

Mobi le : 678-540-7537 .

Emai l : in fo@jor taya l le rgy.com

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