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This will take you to the journala€™s listing within the Online Journals & Databases tool. Allergen immunotherapy (also called allergy vaccine therapy) involves the administration of gradually increasing quantities of specific allergens to patients with IgE-mediated conditions until a dose is reached that is effective in reducing disease severity from natural exposure. Allergen immunotherapy involves subcutaneous injections of gradually increasing quantities of specific allergens to an allergic patient until a dose is reached that will raise the patient’s tolerance to the allergen over time, thereby minimizing symptomatic expression of the disease. Three years of specific immunotherapy with house-dust-mite extracts in patients with rhinitis and asthma: significant improvement of allergen-specific parameters and of nonspecific bronchial hyperreactivity.
Effectiveness of specific immunotherapy in the treatment of asthma: a meta-analysis of prospective, randomized, single or double-blind, placebo-controlled studies. Clinical efficacy of specific immunotherapy to cat dander: a double-blind, placebo-controlled trial. A one-year, placebo-controlled, double-blind house-dust-mite immunotherapy study in asthmatic adults.
A double-blind, multicenter immunotherapy trial in children, using a purified and standardizedCladosporium herbarum preparation. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). Effects of specific immunotherapy in allergic rhinitic individuals with bronchial hyper-responsiveness.
The major objectives of allergen immunotherapy are to reduce responses to allergic triggers that precipitate symptoms in the short term and to decrease inflammatory response and prevent development of persistent disease in the long term. Because the proteins and glycoproteins used in allergen immunotherapy are extracted from materials such as pollens, molds, pelt, and insect venoms, they were originally called allergen extracts.
A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. Allergen immunotherapy is safe and has been shown to be effective in the treatment of stinging-insect hypersensitivity, allergic rhinitis or conjunctivitis, and allergic asthma. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP.
Allergen immunotherapy is not effective in the treatment of atopic dermatitis, urticaria, or headaches and is potentially dangerous if used for food or antibiotic allergies. Despite proven efficacy, the exact mechanism of allergen immunotherapy remains unknown.Selection of PatientsTo make a definitive diagnosis of allergy, IgE-mediated, type I, immediate-hypersensitivity skin testing typically is performed by scratching diluted allergen into the skin surface or by injecting it intradermally. Safe administration of allergen immunotherapy requires the immediate availability of a health care professional capable of recognizing and treating anaphylaxis.

A positive skin test reaction reflects the presence of specific IgE antibodies to the tested allergen, and a correlation of the specific IgE antibodies with the patient’s symptoms, suspected triggers, and allergen exposure is definitive. In vitro, allergen-specific immunoassays to detect serum IgE antibodies are less sensitive than skin testing but may be used in patients with skin diseases that would obscure skin testing results or in those who cannot stop taking medications that suppress the skin test response. Patients should not be taking beta-adrenergic blocking agents when receiving immunotherapy because these drugs may mask early signs and symptoms of anaphylaxis and make the treatment of anaphylaxis more difficult. The circumstances in which allergen immunotherapy is particularly useful are summarized in Table 1.
Unlike antiallergic medication, allergen immunotherapy has the potential of altering the allergic disease course after three to five years of therapy.
They were able to demonstrate a marked reduction in allergy symptom scores and antiallergic medication usage, as well as an alteration in the natural course of allergic disease. Consequently, many allergists have suggested its use earlier in the course of allergic disease.In 2000, the Immunotherapy Committee of the American Academy of Allergy, Asthma, and Immunology (AAAAI) provided a five-year cost comparison of medication usage and single-injection allergen immunotherapy for allergic rhinitis.
Long-term costs deriving from the morbidity and complications of allergic diseases are not established, but allergies usually begin early in life and persist if not treated with allergen immunotherapy. Unstandardized vaccines may vary widely in biologic activity based on manufacturer and by lot, depending on the allergen content of the raw material and the conditions of extraction.
Research is underway on new technologies for DNA and protein analysis that would allow an allergen vaccine to be characterized by the content of the major allergen and the consistency of each lot to be monitored accurately.Vaccine strength is maintained by a number of procedures, including lyophilization and reconstitution with a stabilizer that contains an antimicrobial agent.
A volume effect can occur as a result of adherence of the allergen to the vial surface; the larger the surface area of the vial, the more allergen is lost. At a concentration of 50 percent, glycerol inhibits enzymatic degradation of the allergens, but it may be irritating at this concentration. The combination of human serum albumin as a stabilizer and phenol as an antimicrobial additive often is used.
When a patient has multiple sensitivities caused by related and unrelated allergens, vaccines containing mixtures of these allergens may be prescribed.
As multiple vaccines are mixed, not only will the concentration of each allergen be decreased, but certain allergens will interact. For example, fungi, dust mites, insect venoms, and cockroach have high proteolytic enzyme activity and may be combined with each other but should not be mixed with other allergens. Insect venoms usually are given alone.Vaccine AdministrationThe maintenance concentrate is the dose of vaccine that is considered to be therapeutically effective for each of its constituent components. Maintenance concentration is usually achieved by administering between 18 and 27 serial dose increments at weekly intervals (a build-up schedule written by the allergist) until the maintenance concentrate is achieved. In a typical build-up schedule, the patient will reach the maintenance concentrate in six months, but patients with a higher degree of allergen sensitivity may require a longer build-up phase. The maintenance dose usually is administered every three to four weeks, and maximum benefit typically is achieved in four to five years.

In these situations, communication between the family physician and the prescribing allergist is encouraged to increase safety and avoid unexpected reactions. If the interval between injections is prolonged (Table 4), the dose of vaccine must be reduced; when a new maintenance vial is obtained from the manufacturer, a dose reduction of 50 percent is recommended. The desired injection site is the outer aspect of the upper arm, midway between the shoulder and the elbow in the groove between the deltoid and triceps muscles. The injection is given subcutaneously, preferably with a 26- or 27-gauge needle; if blood is aspirated initially, the vaccine should not be injected. The plunger on the syringe should be depressed at a rate that does not result in wheal formation or excessive pain. Mild pressure should be applied to the injection site for about one minute, and a bandage may be placed if needed. In 1924, Lamson reported the first case of death following immunotherapy.19 A statistical review of the literature about systemic reactions following allergen immunotherapy by Lockey and colleagues20 found that severe systemic reactions occurred in less than 1 percent of the patients receiving conventional immunotherapy in the United States.
From 1985 to 1993 in the United States, 52.3 million administrations of immunotherapy resulted in 35 deaths. These numbers equate to a mortality incidence of less than one per 1 million.21Patients with medical conditions that reduce their ability to survive systemic allergic reactions are not candidates for allergen immunotherapy. Examples of such conditions include chronic lung disease with a forced expiratory volume in one second (FEV1) of less than 50 percent, beta-blocker or angiotensin-converting enzyme (ACE) inhibitor therapy, unstable angina or myocardial infarction, uncontrolled hypertension, and major organ failure. Allergen immunotherapy also cannot be used in patients who would have difficulty reporting signs and symptoms of a systemic reaction, such as children younger than three or four years. Patients who have not been compliant with other forms of therapy are not likely to be compliant with immunotherapy, thus necessitating frequent alteration in dosage schedules and increasing the chance for errors. The immunotherapy dose should not be increased in a pregnant patient until after delivery.Anaphylaxis is the most serious risk related to allergen immunotherapy. The vaccines must be administered in a setting with trained professionals who are equipped to recognize and treat anaphylaxis22A  (Table 7). A retrospective study found that most systemic reactions occurred within 30 minutes of injection.23 Hence, the current recommendation is to allow at least 20 to 30 minutes of observation following an injection. Patients who have had a systemic reaction after more than 30 minutes following an injection require longer observation; in addition, they should be given injectable epinephrine to carry and instructions about how to use it.

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