Allergen immunotherapy: a practice parameter

1 Allergen immunotherapy : a practice parameter Editors: James T. Li, MD, PhD; Richard F. Lockey, MD; I. Leonard Bernstein, MD;. Jay M. Portnoy, MD; and Richard A. Nicklas, MD. Contributors Work Group The Joint Task Force has made a concerted effort to acknowl- Richard F. Lockey, MD, Chair; Tampa, FL. edge all contributors to this parameter . If any contributors Hugh H. Windom, MD; Sarasota, FL. have been excluded inadvertently, the Task Force will ensure Jonathan A. Bernstein, MD; Cincinnati, OH. that appropriate recognition of such contributions is made Roger W. Fox, MD; Tampa, FL. subsequently. Mary L. Jelks, MD; Tampa, FL. Michael J. Reid, MD; San Francisco, CA. Editors John W. Yunginger, MD; Rochester, MN.

2 James T. Li, MD, PhD; Rochester, MN. Richard F. Lockey, MD; Tampa, FL Reviewers I. Leonard Bernstein, MD; Cincinnati, OH Donald W. Aaronson, MD; North Chicago, IL. Jay M. Portnoy, MD; Kansas City, MO David I. Bernstein, MD; Cincinnati, OH. Richard A. Nicklas, MD*; Washington, DC Larry Borish, MD; Charlottesville, VA. *This parameter was edited by Dr. Nicklas in his private Linda Cox, MD; Fort Lauderdale, FL. capacity and not in his capacity as a medical officer with Clifton Furukawa, MD; Seattle, WA. the United States Food and Drug Administration (FDA). David F. Graft, MD; Minneapolis, MN. No official support or endorsement by the FDA is intended John M. Kelso, MD; San Diego, CA. or should be inferred. Alnoor Malick, MD; Houston, TX.

3 Louis Mendelson, MD; Farmington, CT. Robert Miles, MD; Lynchburg, VA. Associate Editors Michael Welch, MD; San Diego, CA. William E. Berger, MD; Mission Viejo, CA David Lang, MD; Cleveland, OH. Joann Blessing-Moore, MD; Palo Alto, CA Richard Weber, MD; Denver, CO. Jean A. Chapman, MD; Cape Girardeau, MO Gary N. Gross, MD; Dallas, TX. Mark S. Dykewicz, MD; St. Louis, MO. Stanley M. Fineman, MD; Atlanta, GA Endorsement Rufus E. Lee, MD; Dothan, AL Allergen immunotherapy : a practice parameter has been Diane E. Schuller, MD; Hershey, PA reviewed and endorsed by the American Academy of Pe- Sheldon L. Spector, MD; Los Angeles, CA diatrics. TABLE OF CONTENTS. I. Preface .. 2. II. Algorithm and Annotations .. 5.

4 III. immunotherapy Glossary .. 6. IV. Introduction .. 7. V. Summary Statements .. 7. VI. Mechanisms of immunotherapy .. 10. VII. Allergen Vaccines .. 10. VIII. Efficacy of immunotherapy .. 13. IX. Safety of immunotherapy .. 13. X. Patient Selection .. 15. XI. Allergen Selection and Handling .. 16. XII. immunotherapy Schedules and Doses .. 19. XIII. Special Considerations in immunotherapy .. 25. XIV. Future Trends in immunotherapy .. 28. VOLUME 90, JANUARY, 2003 1. The American Academy of Allergy, Asthma and Immunol- can Academy of Allergy, Asthma and Immunology, the ogy (AAAAI) and the American College of Allergy, Asthma American College of Allergy, Asthma and Immunology, and and Immunology (ACAAI) jointly accept responsibility for the Joint Council of Allergy, Asthma and Immunology.

5 Work this publication. These clinical guidelines are designed to Group on Atopic Dermatitis. Ann Allergy Asthma Immunol assist clinicians by providing a framework for the evaluation 1997;79:197 211. and treatment of patients and are not intended to replace a The diagnosis and management of anaphylaxis: Joint clinician's judgment or establish a protocol for all patients. Task Force on practice parameters , American Academy of Not all recommendations will be appropriate for all patients. Allergy, Asthma and Immunology, American College of Al- Because this document incorporates the efforts of many par- lergy, Asthma and Immunology, and the Joint Council of ticipants, no individual, including anyone who served on the Allergy, Asthma and Immunology.

6 J Allergy Clin Immunol Joint Task Force, is authorized to provide an official AAAAI 1998;101:S465 S528. or ACAAI interpretation of these guidelines. Recognizing the Li JT, Pearlman DS, Nicklas RA, et al. Algorithm for the dynamic nature of clinical practice and practice parameters , diagnosis and management of asthma: a practice parameter the recommendations in this document should be considered update. Joint Task Force on practice parameters , representing applicable for 3 years after publication. Requests for infor- the American Academy of Allergy, Asthma, and Immunol- mation about or an interpretation of these practice parameters ogy, the American College of Allergy, Asthma and Immu- should be directed to the Executive Offices of the AAAAI, nology, and the Joint Council of Allergy, Asthma and Immu- the ACAAI, and the Joint Council of Allergy, Asthma and nology.

7 Ann Allergy Asthma Immunol 1998;81:415 420. Immunology (JCAAI). These parameters are not designed for Dykewicz MS, Fineman S. Executive Summary of Joint use by pharmaceutical companies in drug promotion. Task Force practice parameters on Diagnosis and Manage- practice parameters Published by the Joint Task Force on ment of Rhinitis. Ann Allergy Asthma Immunol 1998;81: practice parameters 463 518. Spector SL, Bernstein IL, Li JT, et al. parameters for the practice parameters for the diagnosis and treatment of asth- diagnosis and management of sinusitis. J Allergy Clin Im- ma: Joint Task Force on practice parameters , representing the munol 1998;102:S107 S144. American Academy of Allergy, Asthma and Immunology, Portnoy JM, Moffitt JE, Golden DB, et al.

8 Stinging insect the American College of Allergy, Asthma and Immunology, hypersensitivity: a practice parameter . J Allergy Clin Immu- and the Joint Council of Allergy, Asthma and Immunology. J. nol 1999;103:963 980. Allergy Clin Immunol 1995:96:707 870. Executive Summary of disease management of drug Bernstein IL, Storms WW. practice parameters for allergy hypersensitivity: a practice parameter . Joint Task Force on diagnostic testing: Joint Task Force on practice parameters practice parameters , the American Academy of Allergy, for the Diagnosis and Treatment of Asthma. The American Asthma and Immunology, the American College of Al- Academy of Allergy, Asthma and Immunology and the lergy, Asthma and Immunology, and the Joint Council of American College of Allergy, Asthma and Immunology.

9 Ann Allergy, Asthma and Immunology. Ann Allergy Asthma Allergy Asthma Immunol 1995;75:543 625. Immunol 1999;83:S665 S700. Shearer WT, Buckley RH, Engler RJ, et al. practice pa- The diagnosis and management of urticaria: a practice rameters for the diagnosis and management of immunodefi- parameter . Part I: acute urticaria/angioedema. Part II: chronic ciency. The Clinical and Laboratory Immunology Committee urticaria/angioedema. Joint Task Force on practice Parame- of the American Academy of Allergy, Asthma and Immunol- ters. Ann Allergy Asthma Immunol 2000;85:521 544. ogy (CLIC-AAAAI). Ann Allergy Asthma Immunol 1996;. These parameters are also available at http://www. 76:282 294. practice parameters for Allergen immunotherapy : Joint Task Force on practice parameters , representing the Ameri- I.

10 PREFACE. can Academy of Allergy, Asthma and Immunology, the The objective of Allergen immunotherapy : a practice pa- American College of Allergy, Asthma and Immunology, and rameter is to improve the practice of Allergen immunother- the Joint Council of Allergy, Asthma and Immunology. J. apy for patients with allergic rhinitis, allergic asthma, and Allergy Clin Immunol 1996;98:1001 1011. Hymenoptera sensitivity. This parameter is intended to in- Leung DY, Hanifin JM, Charlesworth EN, et al. Disease crease the appropriate use of Allergen immunotherapy ; reduce management of atopic dermatitis: a practice parameter . Joint the underuse, overuse, and misuse of Allergen immunother- Task Force on practice parameters , representing the Ameri- apy; and establish guidelines for the safe and effective use of Allergen immunotherapy , while reducing unwanted and un- This document was developed by the Joint Task Force on practice Para- needed variation in immunotherapy practice .