clinical process for properly prescribe allergen immunotherapy
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DESCRIPTIONClinical process for properly prescribe allergen immunotherapy. Noel Rodriguez-Perez, MD Professor of pediatrics, Allergy& Immunology State University of Tamaulipas, School of Medicine. Clinical process for properly prescribe allergen immunotherapy. - PowerPoint PPT Presentation
Clinical process for properly prescribe allergen immunotherapy Noel Rodriguez-Perez, MDProfessor of pediatrics, Allergy& Immunology State University of Tamaulipas, School of Medicine
Cox L, Nelson HS, Lockey RF. Journal of Allergen immunotherapy: A practice parameter third update Allergy Clin Immunol 2011;127:S1-S46Summary Statement 80: The efficacy of immunotherapy depends on achieving an optimal therapeutic dose of each of the constituents in the allergen immunotherapy extract. AClinical process for properly prescribe allergen immunotherapy
Allergen immunotherapy: What can and cannot be mixed?Esch RE. J Allergy Clin Immunol 2008;122:659-60.
CASE 1: M.D.K. Male. 16 years of agePrevious history: Cows milk allergy in infancy.Hystory: 2 years, recurrent episodes of coriza, nasal congestion, acuous rhinorrea, epifora, fotofobia, intermitent dry cough. Symptoms, perenial with exacerbations in Winter, Spring and summer. Clinical process for properly prescribe allergen immunotherapy
Skin test. Case 1 M.D.K
Case 1: M.D.K.
1. What allergens to be included?2. How many in one vial?3. Can we mix this unrelated allergens?
Zuberbier T, Bachert C, Bousquet PJ, Passalacqua G, Walter Canonica G, Merk H, Worm M, Wahn U, Bousquet J. GA2LEN/EAACI pocket guide for allergen-specific immunotherapy for allergic rhinitis and asthma. Allergy 2010; 65: 15251530. Decision must be based on the allergen which causes:1. The longest duration of symptoms per year 2. The most severe symptoms 3.A major impact on quality of life 4. Which is more difficult to avoid
House dust mitesRelated to perennial symptomsTree pollens Late winter to early SpringGrass pollensLate Spring to early SummerWeed pollensSummer to early AutumnCASE 1: M.D.K.
CASE 1: M.D.K. Pollen SIT Quercus, Celtis, Sorgum, Ambrosia, RumexPollens probably effective dose range: 5 20 mcg (1:100 1:200 w/v)5 pollen mix will dilute each other times 5. Maintenance dose Vial: 1:200 V1 X C1 = V2 X C2 Were: V1 = Final volume to prepareC1 = Desired concentration of extractV2 = Volume of extract needed (unknown)C2 = Concentration of extract you will use (manufacturer concentrate)JACI. 2011;127:S1-S46
CASE 1: M.D.K. Pollen SIT Pollen maintenance vial.Option: 5cc 1:200 w/v V2 = (V1/ C1)xC2V2 (?) = (5cc / 1/200)x1:20 w/v = (5/200)x20 = 0.5V2 = 0.5cc of each pollen extract Mix of 5 pollen extracts: 0.5x5 = 2.5cc + 2.5cc of diluent.
Option: 1:100V2 = (5/100)x20 = 1cc Mix of 5 pollen extracts: 5cc no diluent.
CASE 1: M.D.K: H.D.Mites or standarized Immunotherapy Mites maintenance vial F/Pt mix 50/50.Manufacturer concentrate: 10,000; 30,000 AU/mLEffective maintenance dose: 500 2000 AU or 10mcg/mL (Mf: 10mcg; MPt: 7 12 mcg/mL)Maintenance vial: 2000 AU/mL. V2 = (V1 x C1)/C2V2 (?) = (5cc x 2000)/10,000 AU = 1.0cc V2 = 1.0cc + 4cc Diluent ( 12mcg/mL; 6 mcg/dose)
Major allergen component in standarized extracts
ExtractConcentrationMajor componentContent Effective dose/projected dosePoa annua100k BAU/mL Group 5320 g/mL5 to 20g/ 1000 to 4000AUAgropiron rep 100k BAU/mL Group 5750 g/mL 5 to 20g/ 1000 to 4000AUPhleum Prat100k BAU/mL Phl p5680 g/mL 20g/ 1000 to 4000AUCynodon dact10k BAU/mLGroup 1300 g/mL5 to 20g/ 1000 to 4000AUAmbrosia1:10 w/vAmb a 1290 g/mL 6 to 12g1000 to 4000AUD farinae10k BAU/mLGroup 160 g/mL10 gD pteronisinus10k BAU/mLGroup 165 g/mL 7 a 12 gCat10k BAU/mLFel d 150 g/mL 15 g
Dose of Major component in mcg/mLSuppose 5cc maintenance dose vial for 10 doses of 0.5cc with Timothy grass pollen.5cc must contain 10 times the maintenance dose. Example: Timothy grass maintenance effective dose 20mcg/mL Phl p5. 5 cc maintenance vial must contain 200mcg.Manufacturer label 100000AU/mL = 680mcg of Phl p5/mL.200 divided by 680 = 0.3cc + 4.7cc of diluent.