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Allergy Shots Do they really work?

Allergy Shots Do they really work?. Jonathan L. Bayuk, D.O., FAAAAI, FACAAI. Low Allergen dose. Allergen. Epithelial dammage. FAP. Chemotaxis eosinóphyls. +. INF g IL-12 low conc. Other mediators: Early and late phase. +. Histamine: Early phase. Mastcell. Th2 lympo. B lympho.

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Allergy Shots Do they really work?

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  1. Allergy Shots Do they really work? Jonathan L. Bayuk, D.O., FAAAAI, FACAAI

  2. Low Allergen dose Allergen Epithelial dammage FAP Chemotaxis eosinóphyls + INFg IL-12low conc. Other mediators: Early and late phase + Histamine: Early phase Mastcell Th2 lympo B lympho IL-4, IL-5, IL-13, GM-CSF Degranulation SENSITIZATION ALLERGIC REACTION APC IgE APC = Antigen presenting cell Courtesy of D.Larenas

  3. Allergen Immunotherapy:Definition The repetitive administration of specific allergen(s) to patients with defined IgE-mediated conditions for the purpose of developing immune tolerance to the potential inflammatory effect upon re-exposure to those allergen(s) Adapted from Cox L, Li JT. Nelson H and Lockey R. Allergen Immunotherapy. A Practice Parameter Second Update. J Allergy Clin Immunology. 2007; 120 (3): S25-85.

  4. Indications Indicated for management of IgE mediated disorders: Allergic rhinoconjunctivitis Allergen-induced asthma Hymenoptera and Fire Ant hypersensitivity Used increasingly more for atopic dermatitis

  5. Should Not be used for: Food allergy (yet AND maybe never) Urticaria / angioedema Disorders that are not IgE mediated

  6. Indications for Allergen Immunotherapy • allergic rhinitis, allergicasthma and/or allergic conjunctivitis and evidence of clinically relevant specific IgE AND (one of the following) • poor response to medications, allergen avoidance, or both; • side effects of meds. • Patient does not want to take ongoing meds. • allergic rhinitis and allergic asthma together raise need.

  7. Reduction immediate skin response Early phase =‘blocking antibodies’ IL-10 IgG4/IgA IgE Time Span of Antibody and Skin Test Changes Reduction late skin response Late phase = cellular response Serum concentration 3m 6m Time Adapted from Francis J et al. Journal of Allergy and Clinical Immunology 2008;121:1120-5.e2.

  8. IgG IgG4 blocks IgE-allergen mediated histamine release After Immunotherapy Before Immunotherapy FceRI high affinity IgE receptor Histamine release Mast cells Basophils Mast cells Basophils

  9. SCIT for Asthma(Cochrane Review 2003) Abramson MJ et al. Allergen Immunotherapy for asthma. Cochrane Database Syst. Rev. 2003; (4): CD001186. 75 randomized controlled trials (3188 patients) found improvements in symptoms, decreased medication use, and decreased bronchial hyper-reactivity after subcutaneous allergy immunotherapy (SCIT) Necessary to treat 4 patients with SCIT to avoid 1 deterioration of asthma symptoms and 5 to avoid 1 requiring increased medications Conclusion: Immunotherapy reduces asthma symptoms and decreases use of asthma medications while improving bronchial hyper-reactivity.

  10. SCIT for Allergic Rhinitis (2007 Cochrane Review) Calderon MA et al. Allergen injection immunotherapy for seasonal allergic rhinitis. Cochrane Database Syst. Rev. 2007; (i): CD001936. • 51 clinical DPBC trials (2871 patients) to evaluate symptom scores and medication use -Overall statistically significant reduction in symptom score (p value <0.00001) -Medication score data also showed an overall reduction in the immunotherapy group (p value <0.00001) Conclusion: Allergen immunotherapy effective for decreasing both symptoms and medication use

  11. Odds Ratios and 95% CI forImprovement in Asthma Symptoms after IT Abramson et al. Am J Respir Crit Care Med 1995;151;969-74

  12. Effects of Immunotherapy with Parietaria on Symptoms and Progression to Asthma 2000 2000 Changes in symptom scores at the peak season for allergic rhinitis in adult patients Rhinitis patients developing asthmatic symptoms Polosa et al. Allergy 2004;59:1224-8

  13. El Gato Q: Hey Doc, Should I get rid of my cat? Answer 1: “Yes” conclusion- tell the patient to get rid of the cat, they get rid of the allergist. Answer 2: “Maybe not, if you do allergy shots” aka: allergen immunotherapy.

  14. “The Efficacy of Allergen Immunotherapy with Cat Dander in Reducing Symptoms in Clinical Practice” Biomed Res Int July 31 2013 Objectives: To examine outcomes in allergic asthmatic patients on cat immunotherapy (CIT) compared to allergic asthmatics on traditional immunotherapy (IT) without cat sensitivity. Methods: A Retrospective review over 3 years on CIT and IT respectively and asthma exacerbations. Results: 35 patients in each group. No differences in oral steroid use, acute visits for asthma. Conclusion: (small number study) Allergic asthmatics with cat sensitivity and close dander exposure have similar risk of asthma exacerbation compared to asthmatics on IT without cat sensitivity.

  15. PAT study, 10 year data3 year SCIT: asthma prevention for 10 years N=151/142/109 (Patients without asthma at the beginning of the study, ) 5y 10y 5y 10y 3y 3y Odds-ratio: 3 years= 2.52 (1.3 – 5.1) 5 year= 2.68 (1.3 – 5.7) 10 years = 3.19 (1.3 – 8.1) PAT Study. Moller et al: JACI 2002;109:251-6

  16. Twelve Year Follow-Up After Discontinuation of Preseasonal Grass Pollen Immunotherapy in Childhood Eng.Allergy; 2006: 61:198

  17. Beneficial Effects of 3 to 4 Years of SIT Persist for at Least 3 Years After Discontinuation Initial Placebo Trial Current Trial Pollen Count (grains/m3) Immunotherapy Maintenance Discontinuation None (control) Study group Immunotherapy Placebo Symptom Score May June July Aug. May June July Aug. May June July Aug. May June July Aug. 1989 1993 1994 1995 Durham SR et al N Engl J Med 1999; 341: 468-475

  18. Immunotherapy Prevents the Development of New Allergen Sensitizations New Allergen Sensitization No. of Patients Group None Cat Dog Alternaria Grass Immunotherapy Control 10 0 6 12 4 8 2 6 1 6 22 22 A. Des Roches et al. JACI 1998;99:450-453

  19. Comparison of Mean Healthcare Costs Total healthcare costs for patients who received IT were half those of patients who did not receive IT.Also, arithmetic means allow us to calculate total costs for a given number of patients.

  20. Conclusions??? • Allergen Immunotherapy can work and helps reduce symptoms of asthma and allergic rhinitis in the right setting. • It is used in Allergic Rhinitis, Allergic Asthma, Venom Allergy and possibly Atopic Dermatitis. • Avoidance is key but CIT and IT can be helpful during continues exposure • It cost effective. • Safety…Oh we didn’t talk about that.

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