Monday May 20th
Patient Information for Allergen Immunotherapy for Allergic Rhinitis
Allergen immunotherapy, commonly known as “allergy shots”, has been a mainstay of the treatment for allergic conditions for almost 100 years. In Canada, we are exposed to many of the allergens that have been proven to be effective in this type of treatment. Therefore, many allergists recommend this type of treatment for patients across the country. In this article, we will focus on the use of year round immunotherapy in allergic rhinitis and asthma. We will discuss potential benefits, patient and allergen selection, how the injections are given and safety issues.
Immunotherapy has been shown to be effective for most allergic conditions including allergic rhinitis, asthma, atopic dermatitis and insect sting allergy. As well, there are some studies suggesting that immunotherapy may actually prevent the onset of new allergies or even asthma. The concepts behind allergen immunotherapy are very different than the other common medical treatments that we use in treating allergic conditions such as allergic rhinitis and asthma. The mechanisms behind immunotherapy seems illogical to many. Patients are injected with gradually increasing doses of the allergens that were actually causing their original symptoms. There are several studies performed over the last few decades that have clearly shown that useful changes in the immune system occur with this approach to treatment. In fact, this is the only true treatment that changes the underlying immune problems that cause allergy.
Typically, we approach the treatment of allergic rhinitis by suggesting allergen avoidance measures for the identified allergens. These allergies are identified by skin testing by an allergist. Next, we would typically recommend using non-sedating antihistamines for mild patients and intranasal corticosteroid sprays for moderate and severe patients. Often, patients do not have an adequate improvement with these medical therapies or prefer not to take these medications on an ongoing basis. At this point, allergists may recommend allergen immunotherapy. We estimate that 70 to 80% of patients have a significant improvement with immunotherapy.
As noted previously, the important allergens for each patient are identified by the clinical history of symptoms and the allergy skin tests. In Canada, the most common allergens are dust mites, pets, pollens and molds. All of these allergens can be used in allergen immunotherapy. There are properly performed studies proving that these allergens are all useful for immunotherapy. Furthermore, we now have available standardized allergens for dust mites, cat, grass and ragweed available for patients in Canada. "Standardized" refers to the idea that these allergens are manufactured and tested so that their potency can be more accurately predicted. This has led to more effective immunotherapy that is easier to prescribe by allergists.
If the patient’s symptoms are not controlled by medical therapy, the allergist may prescribe the allergen immunotherapy. Generally, we try to include a maximum of three allergens per vial of serum. For example, we may mix dust mites with ragweed into one vial if a patient is allergic to both of them. Often, we must use two vials of allergy serum because a patient is allergic to several important allergens. Also, some allergens should not be mixed with some other allergens because some allergens can impact the potency of other allergens. Each vial is produced at a full strength concentration. Then that vial is further diluted into weaker vials that are 1/10 strength, 1/100 strength and 1/1000 strength compared to the full strength vial. The patient will receive gradually increasing volumes from the weakest strength vial up to the strongest strength vial. Ultimately, the patient will reach a maintenance volume from the strongest vial of allergen immunotherapy. The increasing doses are given once or twice per week by injection into the arm(s). When the maintenance dose is achieved, then the interval is gradually increased to once per month. Then the maintenance dose is given every month on a year-round basis. Usually, patients have clinical improvement in their symptoms within 6 to 12 months. Private and even provincial drug plans usually cover the cost of the immunotherapy extracts. The injections and medical care associated with them are paid for by public health coverage.
Unfortunately, there are some drawbacks to allergen immunotherapy. For example the length of time to increase the dosing of immunotherapy is usually about six months. Then, the patient stays on the monthly injections for approximately 5 years. One can see that there is a big time commitment to this treatment. Also, there is a risk of allergic reactions to the injections. Occasionally, these reactions can be life-threatening anaphylactic ones. Therefore, patients must wait 30 minutes after each injection in the physician's office. A physician must be present for all allergy injections. As well, generally patients with poorly controlled asthma or patients on beta-blocker medications should not receive allergy injections because of an increased risk of anaphylaxis.
In summary, allergen immunotherapy is a proven treatment in allergic conditions such as allergic rhinitis and asthma that can have a true disease modifying effect. Occasionally, we even are able to "cure" allergic rhinitis or asthma. It is a great option for patients who have not improved with standard medical therapies or who do not wish to stay on medical treatments indefinitely. Finally, a qualified allergist should prescribe immunotherapy and a physician must be present for each injection.
May 11, 2010 | Permalink
THE ORAL ALLERGY SYNDROME
This is a syndrome of allergic sensitization to a variety of fruits, vegetables, and nuts. Symptoms are principally oral and peri-oral, but may be experienced in other organs. The mechanism is believed to be through cross-allergenicity of some foods with a pollen to which the individual has immediate hypersensitivity. The number of specific food triggers listed for each pollen is likely to increase in the future.
Principal groupings of foods with major pollens allergies:
Most patients report itching of the mouth and throat with one or more of the members of the pollen/food group. In the case of fruits and vegetables, it is often restricted to the uncooked food. Symptoms of rhinoconjunctivitis, asthma, hives and angioedema, vomiting, or abdominal pain are more rarely reported after ingestion. Hazelnut may cause life-threatening anaphylaxis. Potato is quite distinct and causes symptoms of rhinoconjunctivitis or asthma only when being peeled or scrubbed.
One report found that amongst patients seen in a referral-based allergy clinic, of those that were birch-sensitive, 50-93% were symptomatic on exposure to apple and/or hazelnut. Without birch-sensitivity, only 6-7% were sensitive to these foods.
Although the symptoms are typically localized to the mouth and throat, up to 4% of patients with this syndrome may develop more severe systemic symptoms. Up to 4% of patients may have gastrointestinal symptoms such as abdominal pain or vomiting.
The best treatment for this syndrome is avoiding the foods that cause symptoms. There are some studies showing that allergy shots or vaccinations may improve the symptoms of oral allergy syndrome.
Practical Guide for Allergy and Immunology in Canada (Medical Resource)
Food Allergy and Anaphylaxis
Airborne allergens are protein particles that can cause asthma, rhinitis and atopic dermatitis. It is important to avoid the allergens that cause allergic symptoms. Avoidance may result in the complete disappearance of symptoms. People should keep their allergies in mind when choosing their environment. In this write up, we will suggest some measures to avoid common allergens.
1.Animals: The ideal method for avoidance of animal allergens is to remove the pet from the home. Symptoms caused by pets can be so long-lasting that it is not apparent to the individual that the pet is responsible for the allergy symptoms until he or she has been away from the pet for a long period of time. It takes months to get the animal proteins to clear from the environment. If the pets cannot be removed, then the pets should be kept out of the bedroom, carpet should be removed from the bedroom, a HEPA filter should be present in the bedroom and the pet should be washed regularly. Please note that these measures are not as effective as removing the pet.
2.Dust Mites: Dust mite are microscopic creatures that live in the pillow, mattress, bedding and carpets in the bedroom. Dust mites eat skin flakes that fall off the body and get water from the ambient air. The allergens from dust mites are from the fecal particles. If you must do the house cleaning, dust-proof Respro™ masks are helpful. The following measures should be completed to avoid dust mites:
a.Hardwood or linoleum are superior to carpet.
b.Mattresses and box springs should be completely encased mite proof covers. Plastic covers can be used on the box spring. Special mattress covers can be purchased at Belgage Pharmacy (525 Belmont Ave. W. Kitchener, 576-2900), ProResp(604A Belmont Ave. W. Kitchener, 886-0202 or 800-363-8051), Vitalaire (4-1373 Victoria St. N., 744-4104), The Pharmacy on King (751 King St. W Kitchener, 578-9991), Medigas (334 Manitou Drive, Kitchener, 893-3250) or in Stratford at Horizon Prohealth (342 Erie Street Suite 114 in Jenny Trout Centre, 272-0202).
c.Pillows and comforters must be machine washable or encased in mite proof covers. All of the bedding should be washed monthly in hot (greater than 55°C ) water.*If there are children in the house caution must be used , as these temperatures can cause burns.
d.Relative humidity above 50% promotes dust mite growth. The ideal humidity is 30 - 40%.
3.Pollens: Pollens from plants that are fertilized by wind-borne pollen can cause allergies. The common pollens in southern Ontario are from trees, grasses and ragweed. Trees pollinate from about April 15 - June 10. Grasses from about May 1 – July 31. Ragweed from August 15 to frost. It is impossible to completely avoid pollens. The best way to avoid pollens is to live and work in an air-conditioned environment. Air-conditioning is effective if all windows in the home are kept closed all season.
4.Moulds: Moulds are outdoors from spring to fall. Keeping windows closed and air conditioning on will decrease exposure to outdoor moulds. Moulds grow frequently in the soil of house plants. It is best to remove any plants that are suspect. Clean humidifiers carefully, at least once monthly. A little bleach in the water helps inhibit mould growth. Mould can be found in bathrooms in the shower area and once again bleach is helpful in removing it. If the basement is humid or you suspect mould is present a dehumidifier may decrease mould.
Air Cleaners: Indoor air can be improved by some air cleaners. One must be aware that manufacturers claims often exceed the real improvement. The most efficient filters are 1. Electronic air-cleaner 2. 3M Filtrete ™ filter 3. HEPA (High Efficiency Particle Absorption) type.
Humidifiers : The ideal humidity is 30 - 40%. Humidity is measured with a hygrometer. Humidifiers should be cleaned with diluted bleach to prevent mould growth.
Duct Cleaning: Dust mites do not live in ducts. Cleaning is recommended when you first move into a house. It is not necessary otherwise. Time and money are better spent on other avoidance measures.
Vacuums: In general vacuums are designed to pick up visible rather than invisible or allergic dust. Many vacuum manufacturers claims are not true. Removing carpet works better then any vacuum for dust mite allergic people. The best vacuum style is a central vacuum system venting to the garage or outdoors.
Smoke: Smoking can cause allergy like symptoms in smokers and people exposed to "second-hand smoke". No one should smoke in the house at all. Allergic people should not smoke!
Patient Information for the First Visit to Our Clinic
Dr. Kim's office is located in the Belgage Medical Arts Building in Kitchener at 525 Belmont Ave. West Suite 205. There is paid parking at the building. If you have been referred to one of Dr. Kim's clinics outside of Kitchener please contact that clinic for specific directions.
The following information is important for your first visit to our clinic:
You should plan your schedule to allow approximately one hour for your first visit.
Medications containing antihistamines should be stopped for 5 days prior to the first visit. DO NOT stop any other medications including nasal sprays or asthma medications. If you cannot stop the antihistamines for 5 days please stay on the antihistamines.
If you have been on allergy shots, please bring in the serum and your dosing schedule.
There have been advances in the methods for allergy testing. The testing involves placing drops on the arms and touching each drop with an allergy tester.
Testing for insect stings, antibiotics and other medications may involve injections of small amounts of the allergens.
If you are referred to the clinic for latex or antibiotic testing please contact the office to be sure your appointment is scheduled for the appropriate date.
For patients under 16 years of age, we request that an adult accompany them for the visit.
Please contact our office if you have any questions. We look forward to seeing you.
Dr. Kim's office is located in the Belgage Medical Arts Building in Kitchener at 525 Belmont Ave. West Suite 205. There is paid parking at the building. If you have been referred to one of Dr. Kim's clinics outside of Kitchener please contact that hospital's clinic for specific directions.
Belgage Medical Arts Centre
525 Belmont Ave. West Suite 205
Kitchener, Ontario N2M 5E2
Tel: (519) 745-9525
Fax: (519) 745-9501
Dr. Kim also has clinics in Stratford, Seaforth and London. To contact these clinics directly please call:
Stratford 519-272-8210 ext. 2415