Risk Factors For Systemic Reactions Research Articles

Precision allergy molecular diagnosis applications in food allergy.

Precision medicine has become important in the diagnosis and management of food allergies. This review summarizes the latest information regarding molecular allergology, an essential component of food allergy managements. Component-resolved diagnostics (CRD) can be used to investigate sensitization to allergens based on symptoms and to reveal co-sensitization and/or cross-sensitization in patients with allergies. The following allergen components are known to be associated with symptoms: ovomucoid from eggs, omega-5 gliadin from wheat, and many storage proteins (Gly m 8 from soy, Ara h 2 from peanut, Cor a 14 from hazelnut, Ana o 3 from cashew nut, Jug r 1 from walnut, and Ses i 1 from sesame). Recent studies on allergens of macadamia nuts (Mac i 1 and Mac i 2), almonds (Pru du 6), fish (parvalbumin and collagen), and shrimp (Pem m 1 and Pem m 14) have provided additional information regarding CRD. In addition, Pru p 7 is a risk factor for systemic reactions to peaches and has recently been found to cross-react with cypress and Japanese cedar pollen. CRD provides information of individualized sensitization profiles related to symptoms and severity of allergies in patients. Clinical practice based on CRD offers many benefits, such as higher diagnostic accuracy and improved management of individual patients.

Risk factors for systemic reactions in typical cold urticaria: Results from the COLD-CE study.

Cold urticaria (ColdU), that is, the occurrence of wheals or angioedema in response to cold exposure, is classified into typical and atypical forms. The diagnosis of typical ColdU relies on whealing in response to local cold stimulation testing (CST). It can also manifest with cold-induced anaphylaxis (ColdA). We aimed to determine risk factors for ColdA in typical ColdU. An international, cross-sectional study COLD-CE was carried out at 32 urticaria centers of reference and excellence (UCAREs). Detailed history was taken and CST with an ice cube and/or TempTest® performed. ColdA was defined as an acute cold-induced involvement of the skin and/or visible mucosal tissue and at least one of: cardiovascular manifestations, difficulty breathing, or gastrointestinal symptoms. Of 551 ColdU patients, 75% (n=412) had a positive CST and ColdA occurred in 37% (n=151) of the latter. Cold-induced generalized wheals, angioedema, acral swelling, oropharyngeal/laryngeal symptoms, and itch of earlobes were identified as signs/symptoms of severe disease. ColdA was most commonly provoked by complete cold water immersion and ColdA caused by cold air was more common in countries with a warmer climate. Ten percent (n=40) of typical ColdU patients had a concomitant chronic spontaneous urticaria (CSU). They had a lower frequency of ColdA than those without CSU (4% vs. 39%, p=.003). We identified the following risk factors for cardiovascular manifestations: previous systemic reaction to a Hymenoptera sting, angioedema, oropharyngeal/laryngeal symptoms, and itchy earlobes. ColdA is common in typical ColdU. High-risk patients require education about their condition and how to use an adrenaline autoinjector.

Systemic reactions to subcutaneous allergen immunotherapy: real-world cause and effect modelling

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.

Higher venom-specific IgE levels differentiate children with previous local large reactions from children with previous systemic reactions of different severity

Introduction: Risk factors for systemic reactions (SRs) from hymenoptera venom (HV) allergy are well known in the adult population but they have been little studied in the pediatric one. Method: The aim of our study was to identify risk factors for SRs in a population of children allergic to HV, comparing a series of clinical (age, gender, atopy, asthma) and laboratory (total IgE, tryptase, venom-specific IgE levels) variables between patients with at least two large local reactions (LLRs) and patients with SRs of different severity for the identified insect. We selected a population of HV allergic children aged <15 years with LLRs or SRs stratified according to Mueller grades after stinging. Results: The population included 80 children, 35 with at least 2 LLRs and 45 with SRs. The level of specific IgE for vespid (Polistes dominula, Vespula species) venoms was significantly higher (p = 0.0321) in children with SRs (Mueller grade II+III+IV) than in those with LLRs and the same significance was also found for specific IgE for Apis mellifera, considering SRs group (Mueller grade I+II+III+IV) in respect with LLRs group (p = 0.0001). Conclusion: The main difference in our pediatric population was the highest level of specific IgE in children with a history of SRs compared to those with a history of LLRs for both vespids and honey bees. These results, once confirmed on a larger population, could suggest the opportunity to follow the behavior of venom specific IgE in children with LLRs to reveal a risk to develop future more serious reactions.

Adverse reactions to subcutaneous immunotherapy in patients with allergic rhinitis, a real-world study.

The efficacy of subcutaneous immunotherapy (SCIT) for allergic rhinitis (AR) have been proven but application is still limited by concerns about the safety. The aims of this study were to investigate the incidence of adverse reactions and to ascertain possible risk factors in patients treated with SCIT in central China. This study retrospectively analyzed the application of SCIT from 2016 to 2018, in 236 patients with AR. After each injection, allergen dosage and details about local reactions (LRs)/systemic reactions (SRs) were recorded. Totaling 236 patients received 5844 injections. The rates of LR were 3.0% per injection and 34.7% per patient, while the rates of SR were 0.48% per injection and 10.6% per patient. 86.9 percent LRs were small. Most SRs were grade 1 (16/57.1%), followed by grade 2 (8/28.6%), grade 3 (4/14.3%). No fatal SRs was recorded. Children, high sensitization and absence of premedication were identified as risk factors for LRs. Recurrent LRs increased the risk of SRs. Premedication could reduce the number and severity of LRs, but not SRs. Dual therapy with antihistamine and montelukast did not provide additional benefit when compared with antihistamine alone. The incidence of SRs was low while LRs were common in SCIT. Children may be prone to develop LRs, while pretreatments could reduce the number and severity of LRs. Recurrent LRs was a risk factor for SRs.

Systemic allergic reactions induced by labile plant-food allergens: Seeking potential cofactors. A multicenter study.

Heat-and-pepsin-sensitive plant food allergens (PR-10 and profilin) sometimes cause systemic reaction. To detect the risk factors for systemic reactions induced by labile food allergens. A retrospective multicenter study was performed on patients with a documented history of systemic allergic reaction to labile plant food allergens and on age-matched controls with a history of oral allergy syndrome (OAS) induced by the same foods. Offending foods, their amount, and state (solid or liquid), and potential cofactors (nonsteroidal anti-inflammatory drugs, protonic pump inhibitors, exercise, alcohol, and fasting) were considered. We studied 89 patients and 81 controls. Sensitization to PR-10 or profilin, IgE to Bet v 1 and/or Bet v 2, and foods causing OAS were similar in the two groups. Twenty patients experienced >1 systemic allergic reaction. Tree nuts, Rosaceae, Apiaceae, and soymilk were the main offending foods. Seventeen (19%) patients were taking a PPI when the systemic reaction occurred (vs 5% in controls; P<.025). The ingestion of the offending food in liquid form (soymilk) was frequent among patients (15%) but unusual among controls (2%; P<.025). Soy milk-induced systemic reactions were independent of PPI treatment. Fasting and excess of allergen, but not NSAID and exercise, were other relevant cofactors for systemic reactions. Systemic reactions occurred without any identifiable cofactor in 39 (44%) cases. PR-10- and profilin-induced systemic reactions are facilitated by PPI, ingestion of large amounts of unprocessed foods, and fasting. Soybean beverages represent a risk for PR-10 hypersensitive patients and should be avoided.

Natural history of systemic reactions and risk factors in children and adults with Hymenoptera venom allergy

Stings by Hymenoptera usually cause just local reactions. However, in some cases, they can induce systemic symptoms and even fatal reactions. The natural history and the risk factors of severe systemic reactions are presented in this review. Both the natural history and risk factors of systemic reactions due to insect stings are unraveled. This publication is based on a selective literature search in PubMed, Web of Science, and EMBASE (until 30 July 2019). Recent publications about insect venom allergy in English journals were analyzed. This literature search included original and review articles and relevant abstracts of allergy congresses in English. Risk factors are classified as follows: (1) patient-related, (2) allergen-related and (3) reaction-related and also risk factor associated to venom immunotherapy (VIT) are considered. Due to the scarcity of data about the suitability of premedication before and during VIT, a succinct table gathering available premedication invites further investigation. There is limited evidence with regard to the natural history of HVA both in adults and in children. Several risk factors may influence the natural history of HVA, namely patient-related, allergen-related and reaction-related. Other factors are inherent to the use of venom immunotherapy (VIT).

Safety of allergen immunotherapy in North America from 2008-2017: Lessons learned from the ACAAI/AAAAI National Surveillance Study of adverse reactions to allergen immunotherapy.

In 2004, it was estimated that one fatal anaphylactic reaction (FR) occurred in every 2.4 million subcutaneous immunotherapy (SCIT) injection visits. Uncontrolled asthma was the most commonly cited factor that contributed to FRs. Results of the annual American College of Allergy, Asthma, and Immunology/American Academy of Allergy, Asthma and Immunology sponsored survey conducted among practicing allergists suggest that one nonfatal systemic reactions (SR) occurred in 0.15% of injection visits and in 0.7% of patients who were treated. Analysis of recent data indicated that FRs are 3.75-fold less frequent. Life-threatening grade 4 anaphylactic reactions are estimated to occur in 0.005% of patients who receive SCIT (or 1/160,000 injection visits). Analysis of data from annual surveys identified the following possible risk factors for SRs: a history of SRs to SCIT, the administration of injections in patients with uncontrolled asthma, use of accelerated buildup regimens, and never adjusting doses during the height of the allergy season. Delayed-onset SRs beginning >30 minutes after injections represented 15% of all SRs in clinics with 30-minute observation periods. The safety profile of sublingual immunotherapy is favorable, with no FRs yet identified for sublingual tablet or liquid formulations. Risk management should focus mainly on patients with uncontrolled asthma by withholding injections in such patients, with recent worsening in asthma symptoms and lung function (e.g., peak expiratory flow rate). Because nearly all FRs and SRs occur within 30 minutes of injections, a 30-minute observation period is recommended. Routinely prescribing epinephrine for all patients did not prevent severe SRs, likely due to poor adherence when SRs occurred. Also, no local or systemic infections were identified in 2.3 million patients attending 24.5 million injection visits, which allayed concerns over infections associated with compounding of allergen extracts by practicing allergists.

Allergy immunotherapy for inhalant allergens: Strategies to minimize adverse reactions.

Background: Allergy immunotherapy (AIT), both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), is an effective and safe treatment for allergic rhinitis and allergic asthma due to inhalant allergens. However, there are many variables in how it is administered. Objective: To review the evidence that suggests the optimal practice(s) to minimize adverse reactions to AIT. Methods: Articles that reported the results of various approaches to the practice of AIT and evidence-based guidelines were consulted for guidance about approaches that would minimize adverse reactions to AIT. Results: Evidence is presented that supports care in the preparation of allergy extracts for treatment; use of modified extracts; location for administration of SCIT and SLIT; risk factors for systemic reactions; AIT in patients on adrenergic blocking agents and angiotensin-converting enzyme inhibitors; use of premedication; the need for prescription of epinephrine autoinjectors; adjustments in dose for pollen seasons, interruptions in treatment, and for local and systemic reactions; and the safety in patients with autoimmune diseases and during pregnancy. Conclusion: Although some of these variables have not been adequately studied, there are many studies that indicate practices that minimize the risk of adverse reactions for both SCIT and SLIT.

Safety of uSCIT-MPL-4: prevalence and risk factors of systemic reactions in real life.

Aim: We assessed the safety of allergoid adjuvanted by monophosphoryl lipid A (uSCIT-MPL-4) in a real-life setting. Materials & methods: Patients treated with uSCIT-MPL-4 were followed-up for 1year. Systemic reactions (SRs) were registered and the association with potential risk factors was evaluated. Results: 2929 patients were included. Grade 0, 1, 2, 3 and 4 SR reactions were observed respectively in 3.3, 1.5, 0.31, 0.07 and 0.07% of patients. A significant association was detected between Grade≥1 SRs and: female gender, number of administrations, previous local reactions. Conclusion: uSCIT-MPL-4 is safe. Local reactions should be accurately assessed as they may represent a risk factor for Grade≥1 SRs, together with gender and number of doses/year.

Venom allergy, risk factors for systemic reactions and the knowledge levels among Turkish beekeepers.

BackgroundAllergic reactions developing after bee sting can be severe and life-threatening. According to epidemiological data, serious systemic reactions range between 1.2%–3%, and this is 2–3 times higher (6%) in beekeeping. In different beekeepers' populations, risk factors of systemic reactions have been investigated and diverse results have been found.ObjectiveThe aim of this study is to evaluate the level of knowledge of beekeepers about venom allergy, epidemiological data, systemic reaction rates, risk factors for systemic reactions, and the rate of emergency admissions after bee sting.MethodsWith the collaboration of Uludağ University Beekeeping Development Research Center and Beekeepers Association, a questionnaire consisting of 19 questions was applied to 242 beekeepers in Bursa and Yalova. Two hundred twenty-one beekeepers who completed the questionnaire were involved in the study.ResultsThe mean age of the beekeepers was 49.9 years (range, 18–75 years). The systemic reaction to bee sting in beekeepers was 37.6%. Allergic rhinitis was found to be a risk factor for systemic reaction. Although 80% of the beekeepers recognized that bee venom could be lethal, only 60% of the beekeepers were aware of immunotherapy, and only 30% were aware of the adrenaline auto-injector drug.ConclusionSimilar to previous studies, we found that the systemic response to the bee sting in beekeepers was higher compared to normal population. Considering the occupational exposure to bee venom and thus higher risk, the awareness of venom allergy in this high risk population was low, and they were poorly informed about the treatment options.

A 10-year experience of a novel and safe modified environmental rush immunotherapy protocol.

Allergen immunotherapy (AIT) is an effective treatment option for allergic rhinitis. Although conventional AIT takes 6 months to reach maintenance dosing, rush AIT accelerates the build-up period and reaches the maintenance dose months earlier. However, accelerated schedules of AIT carry an increased risk of systemic reactions (SR). We aimed to describe a novel 1-day, eight-step modified environmental rush immunotherapy (MERIT) protocol, characteristics of the patients who underwent this therapy, and the safety of this procedure. We also compared distinguishing features of those patients with SRs. We retrospectively analyzed demographic and clinical data of 362 adult patients seen in an outpatient university allergy clinic, from January 2005 to January 2015, and who underwent MERIT protocol treatment for allergic rhinitis. In a univariate analysis, the factors significantly associated with SR were lower body mass index (BMI); younger age; a higher number of allergens in the extracts; and the presence of cat, dust mite, and certain weed pollens. In a multivariate analysis, cat, dust mite, and mugwort were significantly associated with SRs. Over the 10-year period, 50 patients experienced SRs (13.81%), with a total number of 68 SRs. Only 4.7% of the SRs occurred on the MERIT day. Most SRs occurred >30 minutes and were mild. Our MERIT protocol continuation rate for all the patients was 49.2% and did not seem to be influenced by having an SR versus no SR. We present a modified rush AIT protocol that seems to be effective and safe. Most patients tolerated therapy, and only a minority of patients developed SRs, which generally were mild. We identified novel risk factors for SRs that may help determine optimal dosing to decrease the risk of SRs. Ultimately, future studies will be needed to compare the safety of our MERIT protocol with traditional AIT.

The safety profile of subcutaneous allergen immunotherapy in children with asthma in Hangzhou, East China

BackgroundThe aim of the current study is to evaluate the prevalence, severity and possible risk factors of systemic reactions (SRs) to subcutaneous allergen immunotherapy (SCIT) in children and adolescents with asthma in Hangzhou, east China's Zhejiang province. MethodsFrom January 2011 to December 2016, this survey analysed the SCIT-related SRs involving 429 patients (265 children and 134 adolescents) affected by allergic asthma. Recorded data included demographics, diagnosis, patient statuses, pulmonary function testing results before and after each injection, allergen dosage, and details of SRs. ResultsAll patients finished the initial phase and six patients withdrew during the maintenance phase. There were 2.59% (328/12,655) SRs in all injections (3.28% in children and 1.47% in adolescents); 15.62% (67/429) patients experienced SRs (18.49% children and 10.98% adolescents). There were 54.57% SRs of grade 1; 42.37% SRs of grade 2; 3.05% SRs of grade 3; and no grades 4 or grade 5 SRs occurred in patients. Most reactions were mild, and were readily controlled by immediate emergency treatment. There was no need for hospitalisation. The occurrence of SRs was significantly higher in children than that in adolescents (p<0.01). A higher ratio of SRs was found among patients with moderate asthma. ConclusionThis retrospective survey showed that properly-conducted SCIT was a safe treatment for children and adolescents with asthma in Hangzhou, East China. Children and patients with moderate asthma may be prone to develop SRs.

Allergen immunotherapy is safe during pollen season. Results of a 10-year, real-life prospective study

Abstract Objective Although systemic reactions (SRs) due to allergen immunotherapy (AIT) are rare, preventing them is a major concern for allergologists. Natural exposure during pollen season is a controversial risk factor, so some centers reduce AIT's maintenance dose in-season. The aim of this study was to examine whether administering the maintenance dose of subcutaneous AIT (SCIT) during pollen season, without adjustment, is safe. Patients and methods Initially, a retrospective pilot study was conducted, that included thirty-four monosensitized patients treated with perennial SCIT without in-season dose adjustment during maintenance. Pollen counts were monitored with a Burkard trap, to validate the pollen season. Two SRs were registered; one during and the other out of season, showing no seasonal effect on SCIT's safety. A ten-year-long, prospective study using the same SCIT protocol, followed the pilot one. Seventy-eight monosensitized patients, allergic to Grasses or Parietaria or Olive pollen, completed this study, while 28 monosensitized mite-allergic patients served as a control group. Only standardized depot solutions were used. Results A total of 2910 pollen-extracts maintenance-dose injections were administered. Four SRs (Grade 1 or 2, WAO Classification) were registered; 2/1210 during pollen season and 2/1700 off-season. One (Grade 4) reaction, out of 880 mite extract injections, was registered. The presence of SRs did not correlate with any AIT brand. Conclusion In our study population pollen season does not seem to be a risk factor for SRs for monosensitized allergic patients. SRs due to pollen AIT presented with a similar frequency as with mite AIT.

Safety and efficacy of ant rush immunotherapy in children.

The Rush Immunotherapy (RIT) protocol is a valid alternative in order to reach the maintenance phase early. However, there are scarce studies in the literature that have evaluated the safety and the efficacy of an ant RIT process in children. To evaluate the safety and the efficacy of an ant RIT protocol and to identify the risk factors for systemic reactions (SRs) during an RIT procedure in children. A retrospective review was conducted for those children who were receiving an ant RIT procedure. The 3-day RIT protocol consisted of hourly subcutaneous injections in order to achieve a 0.5 ml maintenance dose of a 1:100 weight/ volume (wt/vol) of the Solenopsis invicta whole body extract. The safety for an RIT procedure was monitored by using the World Allergy Organization Subcutaneous Immunology Systemic Reaction Grading System. The efficacy was assessed by the reactions after a field ant re-sting. A total of 20 children who were receiving an ant RIT therapy were reviewed. The mean age was 9.5±3.07 years. There were 6 systemic reactions (SRs) from 324 injections during the RIT procedure (1.85%). All of the systemic reactions were Grade 1-2. There were no associations of SRs regarding age, gender, an atopic history, or the levels of immunoglobulin E (IgE) sensitization to the ants. Among the 14 patients who experienced a field ant re-sting, 4 (28.5%) patients developed Grade 3 SRs. These Grade 3 reactions were resolved after an increase of the maintenance dose to 0.5 ml of a 1:50 wt/vol. There was a significant difference in the mean age of those children who had ant re-sting systemic reactions and those who had no reactions (6.75±0.95 year vs. 10.8±3.29, p=0.036). Rush immunotherapy with ant in children is safe and it has a low occurrence of severe systemic reactions. It is an alternative treatment for those patients requiring a rapid protection.

Risk factors and management of systemic reactions induced by subcutaneous immunotherapy

To explore the risk factors (causes or possible causes) of systemic reactions induced by subcutaneous immunotherapy (SCIT) through clinical observations and develop countermeasures for preventing further SCIT-induced systemic reactions. Each patient on SCIT at our department from December 1993 to September 2013 was inquired about systemic reactions induced by SCIT. Individuals with systemic reactions immediately after SCIT were included. Clinical history and manifestations were inquired and recorded carefully. Risk factors of systemic reactions were probed and analyzed. SCIT schedule was adjusted according to the risk factors and the patients on continuous SCIT were followed up until the end of SCIT course. A total of 70 reactions were observed in 35 patients during the observation period. A large majority (97.1% (68/70) ) of systemic reactions occurred at a maximal concentration of 10(-2). Risk factor included an injection of maximal dosage (0.6-1.0 ml of 10(-2) vial, 27.2% (28/103) ), a further injection of large dosage (0.1-0.5 ml of 10(-2) vial) during pollen season (20.4% (21/103) ), incremental dose regardless of marked local reaction (12.6% (13/103) ), suspected incorrect injection procedure(12.6% (13/103) ) and an injection with a wrong vial of higher concentration (9.7% (10/103) ). Countermeasures were taken accordingly, include stopping injection of maximal dosage, avoiding SCIT of 10(-2) vial on pollen season, decreasing SCIT dosage on existence of large local reactions, performing SCIT only at medical institutions capable of managing anaphylaxis and implementing normalized injection procedures. Most patients (n = 29) finished the course of SCIT successfully without further systemic reactions. Six patients ceased SCIT for personal reasons or on medical advice. Probing the risk factors of systemic reactions induced by SCIT and adopting countermeasures accordingly prevent further systemic reactions. It may provide rationales for preventing or minimizing systemic reactions during SCIT.

Role of immunotherapy in the treatment of allergic asthma.

Allergen-specific immunotherapy (SIT) induces clinical and immunological tolerance as defined by persistence of clinical benefit and associated long-term immunological parameters after cessation of treatment. Although the efficacy of SIT has been shown in terms of reducing symptoms, medication consumption and ameliorating quality of life in both allergic rhinitis and asthma, there has long been some controversies about effectiveness of SIT in the treatment of allergic asthma. The type of allergen, the dose and protocol of immunotherapy, patient selection criteria, the severity and control of asthma, all are significant contributors to the power of efficacy in allergic asthma. The initiation of SIT in allergic asthma should be considered in case of coexisting of other allergic diseases such as allergic rhinitis, unacceptable adverse effects of medications, patient's preference to avoid long-term pharmacotherapy. Steroid sparing effect of SIT in allergic asthma is also an important benefit particularly in patients who have to use these drugs in high doses for a long-time. Symptomatic asthma is a risk factor for systemic reactions and asthma should be controlled at the time of administration of SIT. Both subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT) have been found to be effective in patients with allergic asthma. Although the safety profile of SLIT seems to be better than SCIT, the results of some studies and meta-analyses suggest that the efficacy of SCIT may appear better and earlier than SLIT in children with allergic asthma.

Risk factors for systemic reactions to allergen immunotherapy

To update safety information regarding allergen-specific immunotherapy (ASIT) in clinical practice and highlight the risk factors associated with the adverse reactions, product and each dose. Efforts in recent years have focused on increasing our understanding of the efficacy and safety of ASIT, especially the sublingual variety (SLIT), in multicenter studies. Moreover, new Clinical Practice Guidelines (CPGs) and an international consensus concerning ASIT have been published recently. Although no deaths as a result of subcutaneous immunotherapy or SLIT have been reported in the last 2 years, systemic reactions mainly arising from administration errors still appear. Recent studies support the safety of new forms of specific immunotherapy. An understanding of the risk factors for each patient, product and dose, and the implementation of CPGs are the main factors that could improve the safety of ASIT. The standardization of all procedures for prescribing and administering ASIT, and the systematic collection of standardized safety data in a multicenter database (postmarketing surveillance), may be required to generate new information on the safety of ASIT.

Systemic reactions with aeroallergen cluster immunotherapy in a clinical practice

Subcutaneous allergen-specific immunotherapy is a proven, highly effective treatment for immunoglobulin E-mediated diseases. Despite its proven benefits, only a small percentage of patients with allergic disease use immunotherapy, in part because of the inconvenience associated with treatment. Cluster allergen immunotherapy may offer patients a more convenient treatment option but is prescribed infrequently because of the perception that accelerated immunotherapy buildup leads a higher rate of systemic reactions. To examine the safety of cluster immunotherapy and identify risk factors for systemic reactions during cluster buildup. A retrospective, observational review in a large, multicenter allergy practice group was conducted for patients receiving cluster immunotherapy between May 2008 and October 2010. Data from 441 patients receiving cluster immunotherapy were collected. Forty-eight patients (10.9%) experienced systemic reactions. Based on the World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System, 18 grade 1 reactions (38.3%), 23 grade 2 reactions (48.9%), 5 grade 3 reactions (10.6%), 1 grade 4 reaction (2.1%), and no grade 5 reactions were seen. Risk factors for a systemic reaction included: female sex, physician diagnosis of asthma, age 21 to 40 years, and inclusion of certain allergens in the immunotherapy vaccine. Cluster immunotherapy allows patients to reach their immunotherapy maintenance dose more rapidly and may lead to more rapid symptomatic improvement. However, the cluster buildup may lead to a higher rate of systemic reactions. Identifying risk factors for systemic reactions will help improve the safety of cluster immunotherapy.

Hymenoptera Venom Immunotherapy

Subcutaneous venom immunotherapy is the only effective treatment for patients who experience severe hymenoptera sting-induced allergic reactions, and the treatment also improves health-related quality of life. This article examines advances in various areas of this treatment, which include the immunological mechanisms of early and long-term efficacy, indications and contraindications, selection of venom, treatment protocols, duration, risk factors for systemic reactions in untreated and treated patients as well as for relapse following cessation of treatment. Current and future strategies for improving safety and efficacy are also examined. However, although progress in the past few years has been fruitful, much remains to be accomplished.