Abstract
BackgroundSubcutaneous immunotherapy (SCIT) is an effective treatment for allergic rhinoconjunctivitis. However, adverse events, including life-threatening systemic reactions, may occur. The purpose of this project is to identify risk factors for systemic reactions to SCIT and to provide practice-based solutions using a quality improvement (QI) framework.MethodsA QI initiative was performed in a hospital-based, Canadian Allergy clinic administering SCIT in a 12-month period.ResultsA total of 4242 injections of SCIT were performed over a period of 12 months. Of these, 10 injections resulted in a systemic reaction requiring epinephrine administration (i.e., an incidence of 1 in 424 injections, or 0.24%). Eight patients had at least one documented risk factor for a systemic reaction, and six had multiple risk factors. Major risk factors included seasonal exacerbation of allergic rhinitis, uncontrolled asthma, and an error in route of administration. All reactions occurred with the highest allergen extract concentration.ConclusionThis QI initiative highlights the need for improved patient and health care practitioner education and pre-administration screening. We suggest several considerations for SCIT administration: provide patients with written information on safety; screen patients before injections, including a review of treatment plan adherence and asthma control; adjust dosing to slow down buildup of the most concentrated immunotherapy extract, particularly in high risk patients; and apply additional safety measures in patients with multiple risk factors.
Highlights
Subcutaneous immunotherapy (SCIT) is an effective treatment for allergic rhinoconjunctivitis
The 2016 Immunotherapy Manual published by the Canadian Society of Allergy and Clinical Immunology (CSACI) summarizes several risk factors, including uncontrolled asthma and/or an FEV1 < 70% predicted on spirometry, previous history of systemic reactions to SCIT, SCIT injections from a new extract vial, concomitant treatment with beta-blockers, and administration errors such as an intramuscular injection or a dosing error [1]
Other risk factors include the use of concomitant medications, including the use of an angiotensin converting enzyme (ACE) inhibitor on the day of the injection by one patient (10%), who had taken a non-steroidal anti-inflammatory drug (NSAID) the day prior to the injection
Summary
Subcutaneous immunotherapy (SCIT) is an effective treatment for allergic rhinoconjunctivitis. International societies have sought to develop a consensus on the use of allergen immunotherapy in clinical practice, with landmark contributions from the American Academy of Allergy, Asthma, and Immunology (AAAAI), and the European Academy of Allergy and Clinical Immunology (EAACI) [2, 6]. These reports include a summary of the current state of allergen immunotherapy, with attention to the risk of systemic reactions. The AAAAI, EAACI and CSACI outline additional strategies to reduce the risk of anaphylaxis, including routine screening for symptomatic asthma, avoiding immunotherapy injections in patients with a respiratory infection, fever, or severe exacerbation of allergic rhinoconjunctivitis symptoms, avoiding dose increases and/or considering decreasing doses during peak allergen season, and avoiding strenuous exercise for at least 1 h before and 2 h after injection [1, 2, 6]
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