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1 Indications The severity and duration of a patient s symptoms should be considered when selecting candidates for allergen immunotherapy This treatment is recommended for patients with severe allergic rhinoconjunctivitis who respond poorly to drug therapy, those seeking to lower their long-term medication requirements, and for those whose allergens are not avoidable Immunotherapy is unequivocally effective in patients with allergic rhinitis and allergic conjunctivitis who react to pollens, mold, and house dust mites It reduces immunologic hypersensitivity, symptoms, and medication requirements In children with documented allergic rhinitis, immunotherapy may reduce the risk of subsequent development of asthma The efficacy of immunotherapy in allergic asthma is still debated, but a meta-analysis of 20 randomized, controlled trials done by Abramson showed a positive benefit in patients with allergic asthma The lower clinical response rates observed in asthma have been attributed to the multifactorial nature of the disease Immunotherapy is of no value in atopic dermatitis 2 Immunologic effects Allergen immunotherapy is preferable to desensitization because the immunologic basis for this treatment has not been clearly elucidated Nevertheless, certain immunologic changes can be induced by these injections Circulating levels of IgE antibodies specific to the injected allergens increase slightly during the first few months, then decrease, eventually to substantially lower levels than before treatment Seasonal rises in IgE antibodies to pollens are blunted or eliminated IgG blocking antibody is produced Changes in regulatory T cells favoring suppression of IgE antibody production and apoptosis of antigen-specific T cell clones have been noted TH2 cytokine responses may be shifted toward TH1 responses in peripheral blood mononuclear cells Higher thresholds for release of inflammatory mediators and decreases in late-phase allergic reactions might also be related to the reduction in biologic sensitivity of end-organ systems (eyes, nose, bronchi, and skin) 3 Clinical effects Most patients with allergic rhinitis caused by aeroallergens become more tolerant to natural pollen exposure during successive seasons while receiving immunotherapy A small minority becomes completely asymptomatic, but most patients enjoy a significant decrease in symptoms and medication usage Only highdose injected immunotherapy has been demonstrated to be effective A beneficial response may persist for years after treatment is stopped The clinical effects and immunologic responses are antigen-specific, but the treatment may also decrease the risk of developing new environmental sensitivities 4 Procedure A sterile aqueous solution of the allergen or allergens responsible for the patient s disease is administered by subcutaneous injection in increasing doses once or twice a week until a maintenance dose is reached, at which time the interval is advanced to every 4 weeks The maintenance dose is typically one to ten thousand times the starting dose Ascending doses are used to minimize the risk of systemic allergic reactions during initial stages of
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Treatment of atopy especially allergic rhinitis by the repeated long-term injection of allergen has been shown in many controlled clinical trials to be an effective method for reducing or eliminating symptoms and signs of the allergic disorder
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immunotherapy Three to 5 years is a typical course of therapy Oral immunotherapy remains experimental in the United States, and sublingual or low-dose immunotherapy is unconventional and of unproved efficacy 5 Adverse effects Reactions to treatment may be local or systemic Localized immediate and late-phase skin reactions occur at injection sites These are not harmful, but the dose must be adjusted to avoid excessively large or prolonged local reactions Immediate systemic reactions or anaphylaxis is a potential problem with each injection and must be prevented by monitoring of dosage The patient remains at the treatment facility for at least 20 minutes after each injection so that drugs and equipment for treating anaphylaxis will be available if needed No longterm adverse consequences of aqueous allergen extract immunotherapy are known to have occurred in immunocompetent individuals
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Nelson HS Advances in upper airway diseases and allergen immunotherapy J Allergy Clin Immunol 2006 May;117(5):1047 53 [PMID: 16675331] Stokes JR et al Allergy immunotherapy for primary care physicians Am J Med 2006 Oct;119(10):820 3 [PMID: 17000208]
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