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Allergic Rhinitis & Immunotherapy: Hope or Hype

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Patient Selection
After the clinician has determined that there is a high likelihood that the diagnosis is AR, allergy testing, needed to guide AI, is appropriate. Although not true of specific IgE testing, the accuracy of allergy skin testing results can be adversely affected by several medications. For example, some practitioners may choose to stop first-generation antihistamines two to three days before testing. It is generally accepted that the newer, second-generation antihistamines, which can affect skin-testing results longer, be stopped a week prior to testing.

Patients should be reminded that OTC sleep aids frequently contain antihistamines (particularly diphenhydramine) and that they must be discontinued prior to testing as well. Histamine H2-receptor antagonists such as cimetidine and ranitidine may be stopped a day or two before testing. Although ­β-blockers are only relatively contraindicated in both allergy testing and AI, many health care providers avoid testing and AI in patients taking oral and/or topical (eye drops) β-blocker therapy. Ultimately, the decision is made by individual health care practices.

In vivo allergy skin testing should not be performed on patients taking tricyclic antidepressants and monoamine oxidase inhibitors. Patients with significant cardiovascular disease should not undergo testing or treatment. Pregnancy is a relative contraindication, and allergy skin testing and AI are done only with obstetrician approval. Most allergists avoid allergy skin testing in pregnant women, however, because use of epinephrine, if required, introduces the risk for preterm labor.12,13 Special consideration should also be given to patients with immune deficiencies.

Setting for Allergy Evaluation and Treatment
Recently, many primary care practices have added allergy evaluation and management to the procedures and treatments they offer; however, evaluations and testing traditionally have been performed by allergy and immunology specialists, many of whom include PAs and NPs on their staff. PAs and NPs frequently manage the practices’ allergy programs. Allergists who are listed as American Board of Allergy and Immunology (ABAI)–certified have successfully passed the ABAI’s certifying examination. Other medical specialists, including otolaryngologists and the primary care specialties, are also well placed to evaluate patients with common allergy symptoms and provide appropriate treatment.

Allergy Immunotherapy
AI has now become more efficacious, safer, and more tolerable for the patient than when it was first introduced in 1911. At that time, Leonard Noon authored a brief article claiming that allergen-specific injections could modify AR. Unfortunately, Noon died at age 36 from tuberculosis, but his work was carried on by his associate, John Freeman. Together, they established the guidelines upon which contemporary AI is based, including the protocol to gradually increase the dose of allergen serum, starting with initial weekly to biweekly injections. They also voiced warnings about the potential for anaphylaxis.14 To this day, immunotherapy is still accomplished by the gradual administration of increasing amounts of the allergen to which the patient is sensitive. This tempers the abnormal immune response to that allergen, easing allergic symptoms.

In patients with IgE-mediated hypersensitivity reactions, confirmed by history, physical examination, and allergy skin testing, immunotherapy can be very effective. The results of immunotherapy may last for years and may even prevent the allergic march, the progression of allergic disease experienced by many patients that frequently begins early in life.15 This includes other allergy-related conditions, such as asthma and eczema (atopic dermatitis), and the acquisition of additional new allergies, including those to foods. AI also has been shown to decrease the frequency of comorbidities such as asthma.5 In addition, AI is used in carefully screened patients who desire to reduce the dosages of medication required to control their symptoms.

In a study published in 1999, Durham and colleagues clarified the questions surrounding the amount of time required for ongoing immunotherapy. They found that the desensitization and tolerance to allergens achieved by AI can last up to three years after a three- to four-year course of therapy. They also found that treatment should not start until an allergic component is identified by allergy skin testing or serum tests for allergen-specific IgE.16

As effective as immunotherapy has been documented to be, it is underused as a therapeutic modality. There are only 2 to 3 million patients receiving subcutaneous immunotherapy out of more than 55 million patients with AR.17

On the next page: Types of allergy immunotherapy >>

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