Should Gloves Be Worn When Giving Allergy Shots?

A common question patients ask is whether nurses and or other medical staff be wearing gloves when giving allergy shots (or other forms of immunization).
According to the CDC:

"Gloves are not required when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands." [link]

As such, the practice of wearing gloves is left up to the discretion of the person administering the shot.

Test Video


Some offices/hospitals may have a policy in place that makes it mandatory, but technically it is not required.

Of course, many individuals will point out a conflicting policy based on "Universal Precautions" which can potentially be interpreted as mandatory use of barrier protection (like gloves) whenever there is the possibility of bloodborne pathogen transference (which some may interpret as risk is always present).

However, if one actually reads the Universal Precautions put out by the CDC as it relates to blood drawing (considered higher risk than immunizations),

"In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low. Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy." [link]

Not quite the "mandatory" use of gloves some people stipulate when quoting Universal Precautions policy.


References:
General Recommendations on Immunization. CDC 2/8/02

Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. CDC 6/24/88

Should Gloves Be Worn When Giving Allergy Shots?

A common question patients ask is whether nurses and or other medical staff be wearing gloves when giving allergy shots (or other forms of immunization).

According to the CDC:

"Gloves are not required when administering vaccinations, unless persons administering vaccinations are likely to come into contact with potentially infectious body fluids or have open lesions on their hands." [link]

 As such, the practice of wearing gloves is left up to the discretion of the person administering the shot.

Some offices/hospitals may have a policy in place that makes it mandatory, but technically it is not required.

Of course, many individuals will point out a conflicting policy based on "Universal Precautions" which can potentially be interpreted as mandatory use of barrier protection (like gloves) whenever there is the possibility of bloodborne pathogen transference (which some may interpret as risk is always present).

However, if one actually reads the Universal Precautions put out by the CDC as it relates to blood drawing (considered higher risk than immunizations),

"In universal precautions, all blood is assumed to be potentially infective for bloodborne pathogens, but in certain settings (e.g., volunteer blood-donation centers) the prevalence of infection with some bloodborne pathogens (e.g., HIV, HBV) is known to be very low. Some institutions have relaxed recommendations for using gloves for phlebotomy procedures by skilled phlebotomists in settings where the prevalence of bloodborne pathogens is known to be very low. Institutions that judge that routine gloving for all phlebotomies is not necessary should periodically reevaluate their policy. Gloves should always be available to health-care workers who wish to use them for phlebotomy." [link]

Not quite the "mandatory" use of gloves some people stipulate when quoting Universal Precautions policy.


References:
General Recommendations on Immunization. CDC 2/8/02

Perspectives in Disease Prevention and Health Promotion Update: Universal Precautions for Prevention of Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne Pathogens in Health-Care Settings. CDC 6/24/88

Allergies May Prevent Heart Attacks???

Research has been published suggesting an inverse relationship between serum IgE and heart attacks in the US population independent of coronary risk factors.

No kidding...

This conclusion was reached based analyzing 4002 participants between 2005-2006. They also detected that of the 7 "data-driven, prespecified allergen clusters," house dust mite was the only allergen cluster for which serum IgE is associated with reduced risk for heart attack.

For those wondering, serum IgE is a rough measure of how allergic a patient is generally speaking without any specification of what the patient may be allergic to. It is obtained by bloodwork (RAST or immunoCAP).

The higher the IgE levels, the more allergic a patient is generally speaking. However, one must keep in mind that it may still be possible to be allergic even if IgE is low or vice versa.

Also, although there appears to be a relationship between IgE and heart attacks, it is doubtful it reaches clinical significance for any given patient. Rather, such conclusions may apply to a general population. This study was also retrospective and as such, it would be nice if a new study now looked at a group of allergic patients and see how many suffer heart attacks in the future.

Such un-intuitive relationships just goes to show how complex the human body is where one thing doesn't cause one problem, but rather one thing may affect multiple different aspects of human health.

Now why would IgE and/or allergies in general influence heart attack risk?

Well heart attacks are due to vascular disease (blockage of the coronary artery). Vascular disease is thought to be influenced by how much inflammation is present in the body. The more inflammation present, the higher the risk of vascular disease which in turn increases heart attack rates.

One factor thought to influence the degree of inflammation present in the body is the immune system, and allergies is one part of the immune system.

As such, allergies could be a reflection of what the immune system is doing which in turn influences the degree of inflammation present in the body which in turn affects vascular disease which plays a role in heart attacks.

Reference:
Relation between objective measures of atopy and myocardial infarction in the United States. Journal of Allergy and Clinical Immunology. In Press Aug 27, 2012.

FDA Approves New Epinephrine Injector That Talks

Sanofi US has introduced a new epinephrine injector (competitor to the more commonly known EpiPen made by Dey Pharma LP) that is equipped with audio and visual cues that helps a patient or care-giver administer epinephrine in cases of a severe allergic reaction (anaphylaxis).

Known as Auvi-Q, it was FDA approved Aug 13, 2012, and should soon become available for purchase by prescription.

Just like EpiPen, Auvi-Q comes in two different dosages of epinephrine... 0.3mg for patients who weigh more than 66 pounds and 0.15mg for those who weigh between 33 and 66 pounds. Each pack contains two devices with active drug plus a non-active training device.

During a life-threatening allergic reaction, Auvi-Q talks the patient or care-giver through each step of the injection process. If more time is needed, it can repeat the instructions step-by-step. The device also comes with written instructions printed on the side. In addition, there are visual cues with an alert light to signal when the injection is complete. Watch video.

Auvi-Q is about the size and shape of a credit card, the thickness of a cell phone and fits comfortably in a pocket or small purse. This size and shape is in contrast to the EpiPen which looks like a fat marker. Being compact and easy to carry should remove one obstacle that could be a reason why as many as two-thirds of patients do not carry their epinephrine injector device.

Like the EpiPen, the device also has an automatic retractable needle mechanism to prevent accidental needle sticks.

Source:
FDA Approves Auvi-Q Voice Activated Epinephrine Injector. EmaxHealth 8/13/12

Child's Allergy Risk Higher If Same Sex Parent Has It

British researchers reported this month their findings that a child is at higher risk of allergies if the same sex parent has allergies. In other words, if a father has bad allergies, his sons are at higher risk for them and if a mother has bad allergies, than her daughters are at higher risk for allergy problems.

They based their findings following 1456 children examined at 1, 2, 4, 10, and 18 years of age. History of asthma, eczema, rhinitis, and environmental factors was obtained and skin prick tests were carried out at ages 4, 10, and 18 years, and total IgE measurement was carried out at 10 and 18 years. Parental history of allergic disease was assessed soon after the birth of the child, when maternal IgE levels were also measured.

Keep in mind that the appearance of allergy in a child is not wholly based on genetics but does have some environmental basis as well.

However, the association of gender is a new twist on whether a child will develop allergies or not.

Reference:
The effect of parental allergy on childhood allergic diseases depends on the sex of the child. The Journal of Allergy and Clinical Immunology Volume 130, Issue 2 , Pages 427-434.e6, August 2012

Dirty Air Filters and Allergies - Don't Forget the Car!!!

Most people with bad allergies know to change their home's air filter at least quarterly with at least a 1000 microparticle performance rating (mpr). Such filters will remove pollen, dust, and other airborne particles that may exacerbate allergies as well as keep the vent system within a home clean.

BUT... allergic patients should also not forget to change their car's air filter as well regularly, especially given the car is moving around outside and people often have the air conditioning or heat turned on blowing into the face. And guess what... there are many different quality car air filters.

As such, do recommend that whenever you have your car for maintenance, request the mechanic to show you your car's air filter.

Skin Patch Immunotherapy for Allergy Cure

Over the years, there have been a variety of systems via which physicians and researchers have attempted to cure patients of their inhalant allergies.

These include (click here for a description of each):

• Allergy shots
• Under the tongue allergy drops (SLIT)
• Intra-Lymphatic Injections (ILIT)
• Allergy Tablets
• Epicutaneous Immunotherapy (EPIT)
• Intra-Nasal Spray
• Bronchial Inhalers

Well... we can now add skin patches to the list.

European researchers conducted a placebo-controlled, double-blinded trial involving 132 patients with grass pollen allergies. The patients were randomly divided into one of four groups: placebo, low-dose, medium-dose or high-dose patches. Patients applied six weekly patches prepared with grass allergens prior to and during the 2008 grass season and ALL reported improvement in their symptoms (30% in 2008) though one year later, there was a dose-dependent improvement with essentially no improvement in low-dose and placebo groups.

Unfortunately, higher-dose patches had higher rates of adverse events including pruritus, erythema, wheal, or eczema leading to an overall drop-out rate of 8.3% from the study.

This all may sound good and promising, but two of the study's authors hold patents on patch-based immunotherapy which may lead to study bias.

My take? More study is needed...

Reference:
Epicutaneous allergen-specific immunotherapy ameliorates grass pollen–induced rhinoconjunctivitis: A double-blind, placebo-controlled dose escalation study. The Journal of Allergy and Clinical Immunology Volume 129, Issue 1 , Pages 128-135, January 2012

Food Allergy Reaction Video

So the other day, I was watching the movie Hitchstarring Will Smith and Eva Mendes during which there is this one scene where Hitch suffers an allergic reaction from a food he ate during a dinner date. Watch video.

It's actually a pretty good depiction of a reaction due to a food allergy.

However, given the throat-clearing suggesting airway swelling which extends to his face, he really should have called 911 as this not uncommonly leads to death if the airway swelling is severe enough to obstruct his breathing. Along with facial and airway swelling, his blood pressure probably dropped and his heart rate increased to point he could have passed out due to insufficient blood flow to the brain. Of course, it was a movie and none of that happened, but don't think for a second that benadryl alone is adequate.

It is a little unusual for an adult to have a previously unknown food allergy with this severe a reaction in someone as old as Hitch, but not impossible.

Treatment was appropriately given with benadrylin the movie, but in reality Hitch additionally should have gone to the ER where epinephrine and steroids also would have been administered followed by several hours of observation.

After recovery, he should ALWAYS carry an epipen with him. He should also probably see an allergist to determine what it was he reacted to so that he can avoid it in the future.

On another note, in the movie, Hitch literally chugs down an entire bottle of liquid benadryl and acts drunk from it. That wouldn't have happened... rather, he would have gotten extremely drowsy and fallen asleep fairly quickly.

Laryngospasm and Vocal Cord Dysfunction Video

A new video has been uploaded showing what happens inside the throat when a patient suffering from laryngospasm or vocal cord dysfunction suffers from a breathing attack.

For more information on this condition, click here.

If you are unable to watch the video below, click here to watch it on YouTube.

Why Does the Nose Whistle in Some People?

Though most people like the professional nose whistler shown here require an instrument to enable the nose to whistle, in others it occurs naturally due to unique anatomic features within the nose.

Why might someone's nose whistle?

Septal Perforation

The most common reason it may occur constantly is due to a hole in the septum (septal perforation). The septum is a wall that divides the right nasal cavity from the left side. Normally, it should be straight and without any openings.

However, when a hole is present in the septum and it is in just the right size and place, whenever air is breathed in and out the nose, it will whistle. In this situation, the hole is the "window" of the whistle and the nose itself is the mouthpiece.

Correction of this problem is by either closing the hole (septal button or surgery) or making it bigger such that the aerodynamics eliminate the conditions conducive to nasal whistling. As an FYI, surgical correction of a septal perforation is quite difficult.

Septal Deviation and Some Nasal Congestion

The other situation when the nose may whistle, but only intermittently, is when there is a deviated septum. In this scenario, the septum rather than being straight, it is slightly crooked to one side making one side more narrow than the other.

Add some slight swelling of the nasal lining such that the opening of the nose is restricted to just right size and shape, and it may whistle.

This type of nasal whistling is akin to grass whistling (blowing between two thumbs holding a blade of grass).

Thankfully, the nasal conditions that lead to nasal whistling is quite rare and requires the perfect storm of just the right amount of septal deviation with just the right amount of nasal congestion.

As such, correction of this problem is fairly easy as one needs to change either the congestion causing the nasal lining to swell with a nasal spray or anti-histamine OR fix the deviated septum. If the inferior turbinates are enlarged, they can be reduced in size as well.

Of course, one can take this unusual condition and make it a positive feature worthy of a concert hall... WITHOUT the assistance of any instrument!

Carbon Dioxide Helps with Nasal Allergies

MSNBC reported recently that a shot of carbon dioxide gas into the nose can help with allergies based on preliminary findings funded by Capnia, a company that makes the product.

Upside:
Symptoms of nasal allergies improved within 30 minutes.
No liquid is involved... just carbon dioxide gas.

Downside:
Lasts only 4 hours
80% has nasal discomfort after use
25% became teary eyed
14-20% developed headaches

My take?
I'll pass on this drug... There are already good drugs with minimal side effects that lasts up to 24 hours already on the market .

Read the story here.

Of note, some readers may point out that there is an older study that had better results. With two one-minute carbon dioxide treatments into the nose resulted in symptom relief within 10 minutes and lasted for 24 hours. Even with these results, I'll still pass... not sure how many people will go with 2 one-minute treatments when a 1 second swallow with an allergy pill or nasal spray use works just as good.

Reference:
Nasal carbon dioxide for the symptomatic treatment of perennial allergic rhinitis. Annals of Allergy, Asthma & Immunology - 19 August 2011 (10.1016/j.anai.2011.07.014)

Intranasal noninhaled carbon dioxide for the symptomatic relief treatment of seasonal allergic rhinitis. J Allergy Clin Immunol. Volume 121, Issue 1, Pages 105-109 (January 2008).

Kids Exposed to Fido or Fluffy in the First Year of Life Decreases Risk of Becoming Allergic to Them

There have been a number of studies in the past investigating whether it is healthy for a baby to be around pets and whether such exposure increases or decreases risk of becoming allergic to them later in life.

In a recent study (published online June 2011), the researchers found that among males, those with an indoor dog during the first year of life had half the risk of becoming allergic to dogs at age 18 compared with those who did not have an indoor dog in the first year of life regardless whether born by C-section or vaginally. Also, teens with an indoor cat in the first year of life also had a decreased risk of becoming allergic to cats. Neither cumulative exposure nor exposure at any other particular age was associated with either outcome. So it appears that the FIRST year of life is key to whether a child develops pet allergies or not.

Although in this study, cat and dog ownership appears to be beneficial in kids, prior studies have suggested that for at least cats, it increases risk of overall allergies in children by 13 times! Dog exposure, however, reduces overall allergy by 4 times.

Reference:
Lifetime dog and cat exposure and dog- and cat-specific sensitization at age 18 years. Clinical & Experimental Allergy Volume 41, Issue 7, pages 979–986, July 2011

Genetic and environmental risk factors for childhood eczema development and allergic sensitization in the CCAAPS cohort. J Invest Dermatol. 2010 Feb;130(2):430-7. Epub 2009 Sep 17

Opposing Effects of Cat and Dog Ownership and Allergic Sensitization on Eczema in an Atopic Birth Cohort. J Pediatr. 2011 Feb;158(2):265-71.e1-5.

Anti-Histamine Eye Drops

Allergies often cause eye symptoms of itching, swelling, redness, and tearing.

If other allergy symptoms are also present involving the nose and skin, it is best to try an oral anti-histamine as a first step.

This one oral drug may be able to resolve all these symptoms. As I am fond of telling patients, oral medications affect the whole body as the medication goes to the stomach after swallow, gets digested, and spreads to the big toe just as much as the skin, nose, and eyes.

However, if symptoms are limited to just the eye, it is best to use topical medications like eye drops rather than an oral medication which goes everywhere (where it is not needed).

There are in essence two anti-histamine eye drops available over-the-counter.

The first is the combination of naphazoline and pheniramine found in NaphCon-A and Visine-A (formerly called Ocuhist). Naphazoline is a decongestant that helps eliminate the red eyes whereas pheniramine is an anti-histamine to help eliminate itching. It can be used up to 4X per day for relief.

The other contains the active ingredient ketotifen and has 3 modes of action: anti-histamine, mast cell stabilizer, and eosinophil inhibition. All three actions in essence help resolve current as well as future allergy eye symptoms. It's also why it can be used only twice a day opposed to 4X per day required with naphazoline/pheniramine.

There are three main brands of ketotifen that basically are the same thing:

- Zaditor

- Alaway

- Zyrtec Eye Drops

- Claritin Eye Drops

The "zyrtec" and "claritin" eye drops names are quite misleading in that the eye drops do NOT contain the same ingredient as that found in the oral medication by the same name.

Personally, I prefer ketotifen over naphazoline/pheniramine due to longer-lasting relief per use, 2X per day dosing, and less risk (glaucoma and hypertension specifically). Ketotifen can be used from the age of 3 years (age 6 years for the other).

Of course, if these eye drops don't work, there are prescription antihistamine eye drops that work quite well including pataday/patanol (olopatadine), bepreve (bepotastine),  and lastacaft (alcaftadine). Of course, most insurance companies require trial of OTC eye drops first before they will authorize these prescriptions.

On a final note, there is one steroid nasal spray called Veramyst that has an FDA indication for eye allergies though I suspect all steroid nasal sprays can help similarly. As such, if a patient has only ocular and nasal allergy symptoms, it may be worth trying a steroid nasal spray, though I'm not sure how often this is practiced in reality.

Patients with Iodine or Seafood Allergy CAN Receive Contrast During CT Scans

It is a prevalent belief out in the medical (and lay public) community that patients with iodine or seafood allergy can not receive contrast when undergoing certain radiological tests like CT or MRI scans. The concern is that contrast contains minute amounts of free iodide and as such, IV administration of this material puts the patient at risk of a life-threatening anaphylactic reaction.

Contrast is often given in these tests as it traces out bloodflow enabling the physician to see organ and mass architecture much more clearly allowing for improved accuracy in seeing anything abnormal.

Well... rest assured that patients with iodine and seafood allergy CAN receive contrast without any significant increased risk of an allergic reaction as compared to other allergies.

In a large study encompassing 112,003 patients, only 5% had a reaction. The relative risk of a reaction in patients with seafood allergy was 3.0 compared with 2.9 for those with allergy to eggs, milk, or chocolate; 2.6 for those with allergy to fruit and strawberries; and 2.2 for those with asthma [7]. In other words, a seafood allergy increases the risk of a contrast reaction by about the same factor as does any other allergy. At least 85% of patients with seafood allergy receiving IV contrast material will not have an adverse reaction.

Reference:
Formation of potential antigens from radiographic contrast media. Acta Radiol 1987; 28:473-77
Immunologic basis for adverse reactions to radiographic contrast media. Acta Radial 1990; 31:605-612
Contrast media reactions: experimental evidence against the allergy theory. Br J Radiol 1984;57: 469-173
Adverse reactions to intravascularly administered contrast media. AJR 1975;24: 145-152

New and Only Over-The-Counter Anti-Histamine Nasal Spray

Up until now, there has been three anti-histamine nasal sprays in the United States market available only by prescription... Astelin, Astepro, and Patanase.

However, in May 2011, Meda Pharma announced a new anti-histamine nasal spray Rhinolast Allergy that is available over-the-counter.

The active ingredient is azelastine, the same one as found in the prescription nasal spray Astelin and Astepro.

Azelastine has a triple mode of action: anti-histamine effect, m,ast-cell stabilizing effect, and anti-inflammatory effect. Azelastine has a rapid onset of action of 15 minutes.

It can be used from the age of 5 years.

This nasal spray can be used in combination with other over-the-counter anti-histamines medications taken orally like zyrtec, claritin, allegra, and benadryl.

Read more about this new nasal spray here.

Read more about allergy medications in general here.

Generic Singulair Expected in August 2012

Why August 2012? That's when the patent for singulair, an allergy and asthma medication, goes off-patent. Generic versions of singulair should be expected soon after the patent expires.

For those who don't know... generic versions of medications are much cheaper than brand name medications, but contain the same active ingredient. Here's a list of a few brand name medications relevant in the ENT world with generic names in parentheses.

Flonase (fluticasone)
Prilosec (omeprazole)
Prevacid (lansoprazole)
Claritin (loratidine)
Zyrtec (cetirizine)
Benadryl (diphenhydramine)

Nasal Hair Protective Against Asthma in Patients with Allergies?

Researchers in Turkey found that there is an association between nasal hair density and risk of asthma developing in patients with seasonal rhinitis patients. No joke... They published their findings in the International Archives of Allergy and Immunology in March 2011.

The rate of asthma found in patients with little or no nasal hair was 44.7% whereas only 16.7% of patients with a dense forest of nasal hair had asthma.

They hypothesize that increased nasal hair improves allergen filtration thereby preventing the allergens from irritating the airway. The assumption here being that allergen irritation of the airway can potentially cause asthma.

IF this is true (and that's a big if)... patients with allergies should be encouraged to grow nice thick nasal hair to prevent future asthma!

Read the research abstract here!

Reference:
Does Nasal Hair (Vibrissae) Density Affect the Risk of Developing Asthma in Patients with Seasonal Rhinitis? Int Arch Allergy Immunol. 2011 Mar 30;156(1):75-80

Hypoallergenic Cats and Dogs

CBS news published a story on hypoallergenic pets on their website here.

The story did report that pricey pets that claim to be easy on allergy sufferers are probably more hype than true, but than did go on to list dogs and cats that are purportedly hypoallergenic.

The claim for hypoallergenicity is based on hair/fur/dander length or quantity... mainly the shorter or smaller the amount, the less allergenic. However, there are other reasons why hypoallergenic pets are NOT hypoallergenic. These include a pet's saliva and skin which contain the same protein that trigger allergic reactions.

Also, many dog allergy sufferers also have weed, tree, and grass allergies. If your hypoallergenic dog likes to roll in the grass and weed, they are getting that all over them and bringing it into the house and to you. So even if you are not allergic to the dog, you probably are allergic to what's on the dog.

Read the CBS story here.

Possible Novel Cure for Cat Allergy?

A research team in Canada has developed a possible cure for patients suffering from cat allergy using a novel type of allergy shot called peptide immunotherapy.

To understand the significance of this development, one needs to understand how traditional allergy shots are made. Currently, allergy companies purify a protein called Fel d1 from cats and make a vial out of it. This purification process is like removing the corn kernels from a cornstalk to put into a can to sell at the supermarket.

Peptide immunotherapy as described in this new research is like making the "essence" of the corn kernel in the lab. For this cat vaccine, the key molecule created is a 7 amino acid long peptide sequence.

The benefits of this novel treatment is the lack of side-effects when the shots are administered (meaning, no waiting around after the shot)... and only four to eight shots per year are required (rather than the weekly injections with current allergy shots).

The optimal dose to use is currently being determined in phase three clinical trials.

Reference:
Development and preliminary clinical evaluation of a peptide immunotherapy vaccine for cat allergy. J Allergy Clin Immunol. 2011 Jan;127(1):89-97, 97.e1-14.

Home Allergy Shots

DISCLAIMER: This post is not meant to condone or promote allergy shots to be given at home. It is meant to promote discussion and make patients aware of the issues involved.

Allergy shots, unlike medications like claritin and flonase, offer patients with significant allergies a way to potentially be cured of their misery without the need for daily medication use. However, there is a small, but substantial risk for anaphylaxis and even death with allergy shot administration. After all, a patient is being injected with the very substances that cause their allergies. As such, many allergists will allow allergy shots to be administered ONLY within a medical setting. Also, the American Academy of Allergy Asthma and Immunology (AAAAI) specifically forbids allergy shots to be administered at home.

Furthermore, the allergen extracts used to make the allergy vial serum used for allergy shots carry a black box warning on the medication package insert:

"This product is intended for use only by physicians who are experienced in the administration of high dose allergy injection therapy, or for use under the guidance of an allergist. Allergenic extracts may potentially elicit a severe life-threatening systemic reaction, rarely resulting in death. Therefore, emergency measures and personnel trained in their use must be available immediately in the event of such a reaction. Patients should be instructed to recognize adverse reaction symptoms, be observed in the office for at least 30 minutes after skin testing or treatment, and be cautioned to contact the physician's office if symptoms occur. Standardized glycerinated extracts may be more potent than regular extracts and therefore are not directly interchangeable with non-standardized extracts, or other manufacturers' products. Patients with cardiovascular diseases and/or pulmonary diseases such as symptomatic unstable, steroid dependent asthma, and/or those who are receiving cardiovascular drugs such as beta blockers, may be at higher risk for severe adverse reactions. These patients may also be more refractory to the normal allergy treatment regimen. Patients should be treated only if the benefit of treatment outweighs the risks. Patients on beta blockers may be more reactive to allergens given for testing or treatment and may be unresponsive to the usual doses of epinephrine used to treat allergic reactions. This product should never be injected intravenously."

The downside of allergy shots is that they are given 1-2X per week not just for a month or two, but for YEARS. If shots are given only within a medical facility, the patient must commit a significant amount of time, travel, and gas in order to complete a shot series. There is also the time missed from work. In essence, the patient must approach allergy shots like a part-time job.

Given all this... what are the actual risks of anaphylaxis and death from allergy shots?

VERY small...

In one Mayo Clinic study on 79,593 immunotherapy injections over a 10-year period showed the incidence of adverse reactions to be less than two-tenths of 1 percent (0.137 percent). Most of the reactions were mild and responded to immediate medical treatment. There were no fatalities.

More than 1 million injections were given without a fatality to 8,706 patients in allergy clinics at Roosevelt Hospital, New York City, between 1935 and 1955.

Worldwide, there were only 35 deaths reported from allergy shots between 1985 - 1993. It has been estimated that during that period there were 52.3 million immunotherapy procedures, making the incidence of fatality less than one per million (0.6692 per million). Data recently compiled by the Allergen Products Manufacturers Association (APMA) estimated the incidence of fatalities to be about three per 190 million annual injections, or approximately one per 63 million injections.

Now compare this to other medical interventions. Approximately 1 in 5000 exposures to a IV dose of penicillin or cephalosporin antibiotic causes anaphylaxis of which more than 100 deaths per year are reported in the United States. Fatal reactions to penicillin have ranged from 0.4 fatalities per million injections to 1 fatality per 7.5 million injections.

One to 2% of people receiving IV contrast (for a CT scan) experience some sort of systemic reaction. The majority of these reactions are minor, but fatalities have occurred in about 1 in 13,000 to 1 in 75,000 procedures in the 1980s (a more recent study has shown a decrease of 1 fatality in 169,000 procedures).

So... the main question now is should home allergy shots ever be allowed?

There are two ways of answering this question.

The first way is to consider any fatality due to an allergy shot (no matter how extremely rare) to be unacceptable, especially when considering the disease being treated -- allergies -- to be a quality of life issue rather than a life/death issue (heart transplant surgery). There is also that black box warning mentioned above.

The other way to view the answer is to consider things in perspective. There are MANY quality of life activities that people perform that has a risk of severe bodily harm if not death. Swimming results in 1,150 deaths per year in the United States alone. There are about 43,000 fatalities per year from car accidents.

Also, if one takes the stringent view that any fatality due to an allergy shot to be unacceptable, than patients should be monitored in a medical facility for not just 30 minutes or less, but 24 hours as late reactions can still occur the following day after an allergy shot! Indeed, in England, patients are required to wait under observation for anaphylaxis as long as ONE HOUR after each and every injection!!! In fact, the one hour observation was an improvement over the TWO hours that was imposed initially. Read more about this here.

So why draw the line at 20 minutes (or more) as recommended by the AAAAI in the United States? It's because the vast majority of severe reactions occur within the first 30 minutes. Beyond 30 minutes, severe reactions become less common (but NOT zero). Well, severe reactions are not very common to begin with... and if allergy shots must be given in a medical facility due to this concern... than should it not follow logically that no matter how rare the possibility, that patients MUST be observed for 24 hours no matter how small the risk of anaphylaxis than?

Why state that allergy shots must be given in a medical facility due to small, but possible risk of severe reaction on the one hand, and than state that there is a small, but acceptable risk of severe reaction after 20+ minutes of observation in a medical facility?

It is just through this thought process that some physicians who provide allergy shots allow home injections. At this time, it is estimated that about 15% of allergists allow home injections (based on a blinded survey of allergists).

IF home allergy shots are allowed (and this is by no means a recommendation or a statement condoning home allergy shots, but just saying in a hypothetical sense), it should be done only in carefully selected patients:

- Are on maintenance regimen (allergy shots are not being increased)
- No significant reactions during buildup and maintenance
- Proper training in administration (just like diabetics are trained to give themselves their shots)
- Epi-pen available and understanding in how to use
- In-office allergy shot with post-injection monitoring for a period of time with every new vial
- Only in adults
- CONSENT signed by patient informing of the risks as well as black box warning



References
Systemic reactions to immunotherapy at the Mayo Clinic. J Allergy Clin Immunol 1997; 99:S66.

The risk of inducing constitutional reactions in allergic patients. J Allergy 1957; 28:251-261.

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