What is it?
Immunotherapy, sometimes also referred to as “allergy shots,” is a way to treat some allergic diseases and induce a long-lasting period free of symptoms. It does not simply treat the symptoms, but is a “disease modifying” therapy that addresses the problem that causes the symptoms. Allergy treatment in this way can improve symptoms of rhinitis (nasal allergy), asthma, and possibly dermatitis (eczema).
When do we use it?
Immunotherapy is intended for patients who have positive skin or blood tests to allergens and a history of symptoms when exposed to allergens. It is a alternative choice for those who are unable to avoid allergen exposure, do not do well on medical therapy, are unable to take medications, have side effects from medications or are interested in potential long-term benefits after treatment. Alternatives to immunotherapy are avoiding allergen exposure and using medications to treat symptoms.
How does it work?
The goal is to change the way your immune system reacts when exposed to allergens and to make you tolerant of them. The best results are achieved at the highest dose, referred to as the maintenance dose, but improvement is often gradual during the first several months of treatment. Most people improve and use less medicine. The best outcome results in you experiencing no symptoms and using little or no allergy medication. People usually get better during the first year of treatment and this benefit can last even after maintenance injections are eventually stopped. How and where is it given? At this time, in the United States, the only FDA approved form of immunotherapy are by injection under the skin or by tablet taken under the tongue (sublingual). Immunotherapy does not contain drugs but are allergen extracts of naturally occurring substances such as plant pollens (tree, grass and weed), molds, dust mites and animals. People allergic to stinging insect venom can also be treated with immunotherapy, but those allergic to food or drugs cannot. Injections must be given in a medical facility with equipment and personnel trained in administering ITX and in treating any injection reactions. The first dose of sublingual immunotherapy tablets must be given in a medical facility in the same manner as the injections. However, the remainder of the doses can be taken at home if the physician believes that it will be safe.
How long do I stay on it?
There are two phases to immunotherapy, build-up and maintenance. A treatment set of 5 vials of allergen serum is prepared. They range from one that is quite diluted (vial 1) to a strongest solution (vial 5). Depending on the number of allergens used for treatment, you may have one or two sets of vials and therefore one or two injections. The build-up period involves treatments once or twice weekly with increasing doses of extract beginning with a small dose from vial 1 and then progressing to the higher dose in vial 5. During the maintenance phase the highest dose reached is given less frequently, usually once every 2-4 weeks, depending on how long you have been on treatment. A typical course of treatment involves 5-10 months of build-up and 3-5 years of maintenance injections. At each visit one dose is administered from each vial followed by a 20-30 minute observation period in which the patient remains in the office until they have been checked by the allergy nurse. The treatments are given during the designated allergy injection hours for each office and no appointment is needed. A physician is required to be present during the allergy injection hours in cases of emergency. On rare occasions we may have to make changes to our normal shot hours. If this is the case, we will provide monthly schedule changes; these are available from the allergy receptionist and they are listed on our website. Sublingual tablets have one phase with one tablet taken every day.
Can I build-up faster?
There is a more rapid form of build-up called “Cluster Immunotherapy” that allows you to reach the maintenance dose sooner. This treatment is not suitable for all patients. Using the cluster schedule, you will reach your maintenance dose in approximately 2-3 months, instead of 5-10 months using the standard schedule. This reduces the number of visits needed to reach the maintenance dose from approximately 38 visits (using the standard schedule) to 14 visits (using the cluster schedule) but these visits will take longer. You can plan on being in the office for at least 2 hours during the first four visits. Cluster visits will generally be once a week and you will need to schedule a dedicated appointment time. The risks of the cluster injection schedule may include a higher chance of an allergic reaction since the dose is increased at a rapid pace. During cluster build-up, for the first four visits you will receive 4 doses per day of increasing amounts from each vial spaced 30 minutes apart. (If you have 2 sets of vials, you will receive a total of 8 injections.) Vital signs will be obtained before and after the session and if you have asthma a pulmonary function test will be performed before injections begin. You and your physician will decide if this treatment is appropriate for you.
Are there any risks?
As with any type of medical treatment, immunotherapy can carry some risks. The treatment extracts contain allergens to which you are sensitive and can cause an allergic reaction. Injection reactions can occur with either cluster or standard build-up schedules and higher doses are more likely to cause a reaction than lower ones. Two types of reactions can occur, local and systemic. Local reactions are the most common ones and consist of itching, redness, swelling, and warmth at the injection site. These are usually small, not bothersome and can be ignored. However, on occasion they can be larger and may be treated. Systemic reactions are less common and include itching away from the injection site, hives, sneezing, congestion, asthma or gastrointestinal symptoms. Severe systemic reactions are rare but can include loss of consciousness and shock and can be fatal (approximately 1 fatality per 3 million injections). Most systemic reactions occur within 20-30 minutes after the injection being administered during the waiting period and can be promptly treated. However, delayed systemic reactions can still occur. If this ever happens, we recommend that you return to the office for treatment or, if it is after hours, call our office and the On-Call Allergist will be contacted. If you ever believe you are having a severe reaction, we recommend that you promptly go to the nearest emergency room for evaluation and treatment. Local and systemic reaction can occur with sublingual therapy. Local reactions include itching of the mouth, throat irritation, ear itching, mouth swelling, tongue itching, cough and mouth pain. Systemic reactions are less common and are similar to the systemic reactions seen in injection immunotherapy. Patients will be given an epinephrine autoinjector (Epipen) to use if they are experiencing systemic symptoms at home. If you experience a systemic reaction, we recommend that you use our Epinephrine and call 911.
How much does it cost?
There is an office visit fee for obtaining and preparing the serum and another for giving the injections. Cluster build-up immunotherapy also involves an office visit fee. Your insurance company will determine how much they cover of these fees; coverage can vary widely between companies and between their specific plans. We strongly advise that you contact your insurer to obtain this information before deciding on whether or not to undergo immunotherapy. You are responsible for any deductibles and copayments due at the time of service of the allergy injection. Sublingual immunotherapy is a prescription tablet. Your physician will write a prescription for you to pick up at the pharmacy and bring to the first visit. The cost will be determined by your prescription plan.
Is there anything I need to do to prepare before injections or sublingual immunotherapy?
Once you have decided to proceed with allergy injections, you will need to contact our office at (410) 760-8840, and ask to speak with the allergy nurse at the location you will be receiving your injections to make them aware you would like to proceed with allergy injections. Serum will not be prepared until a verbal authorization has been given by the patient or the patients’ parent/legal guardian. If your insurance company requires a referral for allergy services, you are required to obtain a referral from your Primary Care Physician before your serum can be mixed and start your allergy injections. To assure that a proper referral is on hand, we encourage you to call ahead to verify that we have received the referral. For sublingual immunotherapy, contact our office at (410) 760-8840, ask for the allergy nurse at the location you plan to receive your first dose of sublingual immunotherapy. You will be contacted by a special scheduler to schedule your appointment. Please bring your medication and epinephrine (Epipen) to the first visit. You will have a visit with the doctor, your vital signs and peak flow will be taken. You will take the first dose and be observed for 30 minutes for signs of allergic reactions and treated if symptomatic.