The American Academy of Otolaryngic Allergy (AAOA) recognizes the importance of allergy skin testing and immunotherapy in the clinical practice of allergy.

Although felt to be a safe practice in most patients, certain populations need to be given special consideration as they have been identified as being at a higher risk for compli- cations during skin testing and treatment of allergies with immunotherapy. This is not intended to be an all-inclusive list.

Pregnancy

Allergy immunotherapy can be continued during pregnancy. Escalation and skin testing should be avoided.

The most recent update on allergen immunotherapy states that allergen immunotherapy can be continued but is usually not initiated in the pregnant patient. Allergen immunotherapy is usually not initiated during pregnancy because of concerns about the potential for systemic reactions and the resultant adverse effects on the mother and fetus. For this reason, if the patient becomes pregnant during escalation and the dose is unlikely to be therapeutic, discontinuation of immunotherapy should be considered.

Asthma

Asthma patients should be under good asthma control prior to undergoing skin testing or before the initiation or continu- ation of immunotherapy. In asthma patients, consider evaluat- ing lung function prior to administration of immunotherapy.

Immunotherapy is effective in the management of allergic asthma; however, uncontrolled asthma has been repeatedly identified as a high-risk factor for systemic reactions during skin testing and allergen immunotherapy.

The most recent update on allergen immunotherapy states that allergen immunotherapy in asthmatic patients should not be initiated unless the patient’s asthma is stable with phar- macotherapy. It is also recommended that allergy injections should be withheld if the patient presents with an acute asthma exacerbation. Before the administration of an allergy injection, the asthmatic patient should be evaluated for the presence of asthma symptoms. One might consider an objective measure of airway function (peak flow).1, 2

Beta Blockers

The AAOA recognizes that exposure to a beta-adrenergic blocking agents is a risk factor for more serious and treat- ment resistant anaphylaxis. Therefore it is preferable to not perform inhalant skin testing and immunotherapy on patients taking beta blockers.

The balance of possible risks and benefits is not the same for patients with the potential for life-threatening stinging insect reactions who are also taking a beta– blocker. In these patients, the benefits of venom immunotherapy may outweigh any risk associated with concomitant beta-adrenergic blocker admin- istration. The individualized risk/benefits of immunotherapy should be carefully considered in these patients.

Beta blockade can enhance mediator release in the setting of IgE-mediated anaphylactic reactions. Therefore, concom- itant treatment with beta-adrenergic blockers may result in more protracted and difficult to treat anaphylaxis. Studies looking at patients taking ophthalmic and cardio-selective

beta-blockers have found unusually severe anaphylactic reac- tions and for this reason, the absence of increased risk in this population cannot be assumed.3, 4, 5, 6, 7

Other Risk Factors

Other predictors of future allergic reactions include, prior allergic reactions, immunotherapy escalation, first treatment vial and technical (dosing/wrong vial) error.8, 9

Review AAOA’s Clinical Care Statements

References:

1. Cox L, Nelson H, Lockey, R. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127(suppl): S1-55

2. Lockey RF, et al. Systemic Reactions and fatalities associated with allergen immu- notherapy. Ann Allergy Asthma Immunol 2001; 87:47-55.

3. Hepner MJ, et al. Risk of systemic reactions in patients taking beta-blocker drugs receiving allergen immunotherapy injections. J Allergy Cl in Immunol 1990;86:407

4. Lang DM. Do beta-blockers really enhance the risk of anaphylaxis during immuno- therapy? Curr Allerg Asthma Rep 2008; 8:37

5. Odeh M, Oliven A, Bassan H. Timolol eyedrop-induced fatal bronchospasm in an asthmatic patient. J Fam Pract 1991;32:97-8, NR

6. Cox L, Nelson H, Lockey, R. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011;127(suppl):S1-55

7. Lieberman P, et al. The diagnosis and management of anaphylaxis practice parameter: 2010 Update. J Allergy Clin Immunol 2010;126(3): 477-523

8. Roy SR. et al. Increased frequency of large local reactions among systemic reac- tors during subcutaneous allergen immunotherapy. Ann Allergy Asthma Immunol 2007; 99:82.

9. Bernstein DI, et al. Twelve-year survey of fatal reactions to allergen injections and skin testing: 1990-2001. J Allergy Clin Immunol 2004;113:1129