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Immunotherapy

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Diana Birch, BSc (Hons), RN, DipAsthma;Andrew Williams, RN, DipAsthma.

Diana-formerly Clinical Research Nurse (Allergy and ENT), National Heart and Lung Institute, London; Andrew-Allergy Research Nurse, Homerton University Hospital, London

Immunotherapy, also called desensitisation or allergy vaccination, is usually undertaken with a series of injections that help the body to gradually build 'immunity' to allergens. Although used world-wide, allergy vaccination is limited in the UK (apart from for research purposes) to bee and wasp venom and grass pollen allergies.
Immunotherapy, also called desensitisation or allergy vaccination, is usually undertaken with a series of injections that help the body to gradually build 'immunity' to allergens. Although used world-wide, allergy vaccination is limited in the UK (apart from for research purposes) to bee and wasp venom and grass pollen allergies.


Specifically trained specialist nurses and doctors administer immunotherapy. These services have, until 2001, been accessed on an NHS 'named patient' basis or as part of clinical trials. This position is currently subject to review by the Medicines Control Agency following the results of a major nation-wide trial due for completion in September 2002.


Incidence
Patients with severe seasonal allergic rhinitis caused by grass pollen that is unresponsive to other treatments may be candidates for immunotherapy. A detailed patient history is required. See the Factfile on allergic rhinitis, page 403.


Benefits of immunotherapy
Although patient satisfaction with symptom improvement rates is not always recorded, there are suggestions that 70 to 80% of patients were satisfied or very satisfied with treatment (Frank et al, 2001). A recent study showed that symptoms can be reduced by 50%, need for medication reduced by 80% and seasonal chest symptoms reduced by 90% (Walker et al, 2001).


Administration
Patients receive a weekly subcutaneous injection for the first few months of conventional immunotherapy. The first injection is a very dilute solution of the vaccine. The concentration is gradually increased each week for several months, according to a predetermined schedule that can be modified to suit the patient's tolerance. Usually the highest concentration, or maintenance dose, is reached four to six months into immunotherapy. A maintenance dose is then given every one to two weeks and then extended to every three or four weeks. The course lasts three years to produce optimum benefit (Durham et al, 1999).


There are now 'modified' immunotherapy preparations that require only seven injections (Frank et al, 2001). These are likely to enable more people to benefit due to the reduced commitment in terms of time.


Safety
Immunotherapy should be performed only by appropriately trained staff in specialist centres with immediate access to resuscitation equipment, according to the international consensus report on diagnosis and management of asthma (WHO, 1992). It is contraindicated in patients with perennial asthma because they are more likely to develop severe adverse reactions (Frew, 1993).


Allergen immunotherapy injections are usually safe but very rarely a patient may have a life-threatening anaphylactic reaction to the vaccine. Therefore, the following precautions should be taken:


- Intramuscular adrenaline, intravenous antihistamines, corticosteroids, oxygen and nebulised salbutamol should always be to hand (RCUK, 2002)


- Adherence to the 60-minute observation period post-injection is vital for monitoring early adverse events


- Prophylactic treatment with an antihistamine 15 minutes before injection can help reduce the incidence of unwanted side-effects (Walker et al, 2001).


Side-effects
Local reactions at the injection site (swelling/itch) are common and to be expected. With 'modified' allergen immunotherapy it is thought that severe reactions are less likely to occur because the pollen is washed in a chemical that reduces its allergenicity.


Immunotherapy products
There are two main products that are used in the UK:


- Alutard SQ: (manufacturer Alk Abelló). This consists of one grass named Timothy grass, which has the Latin name Phleum pratense


- Allergovit: (manufacturer Allergopharma). This consists of six different grasses.


Summary
Immunotherapy is effective and safe when carried out by properly trained and equipped health professionals on patients who have been carefully selected and screened. Access to these treatments is limited because, although allergy has a high profile with the public, this has yet to translate into adequate service availability.


Useful addresses
British Allergy Foundation, Deepdene House, 30 Bellegrove Road, Welling, Kent DA16 3PY. Helpline: 020-83038583. www.allergyfoundation.com


The Anaphylaxis Campaign, 2 Clockhouse Road, Farnborough, Hampshire GU14 7QY. Tel: 01252- 542029. www.anaphylaxis.org.uk

Durham, S.R., Walker, S.M., Varga, E.M. et al. (1999) Long-term clinical efficacy of grass pollen immunotherapy. New England Journal of Medicine 341: 468-475.

Frank, E., Williams, A., Cromwell, O. et al. (2001) Effectiveness of a pre-seasonal allergoid immunotherapy in patients with seasonal allergic rhinitis due to grass pollen (abstract). Journal of Allergy and Clinical Immunology 107: 2, 260.

Frew, A.J. (1993) Immunotherapy (British Society of Allergy and Clinical Immunology working party). British Medical Journal 307: 919-923.

Resuscitation Council UK. (2002) Emergency Medical Treatment of Anaphylactic Reactions for First Medical Responders and for Community Nurses. London: RCUK.

Walker, S.M., Pajno, G.B., Lima, M.T. et al. (2001) Grass pollen immunotherapy for seasonal rhinitis and asthma: a randomized, controlled trial. Journal of Allergy and Clinical Immunology 107: 1, 87-93.

World Health Organization. (1992) International consensus report on the diagnosis and management of asthma: international management project. Allergy 47: 1-61.
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