Allergy Immunotherapy in the College Health Setting New York State College Health Association 2010 ANNUAL MEETING Mary Madsen RN – BC Assistant Director, Clinical Operations University Health Service University of Rochester New York State College Health Association 2010 ANNUAL MEETING Mary Madsen RN – BC Assistant Director, Clinical Operations University Health Service University of Rochester

Allergies: immune system overreacts by producing antibodies called Immunglobulin E (IGE) these travel to cells and release chemicals, causing the allergic reactions  Allergy shots (immunotherapy) are aimed at increasing your tolerance to allergens that trigger your symptoms  Allergy shots work like a vaccine, your body responds to the increased injected amounts of a particular antigen and develops a resistance and tolerance  Indicated for allergic asthma, allergic rhinitis/conjunctivitis, stinging insect allergy  Allergy shots (immunotherapy) are aimed at increasing your tolerance to allergens that trigger your symptoms  Allergy shots work like a vaccine, your body responds to the increased injected amounts of a particular antigen and develops a resistance and tolerance  Indicated for allergic asthma, allergic rhinitis/conjunctivitis, stinging insect allergy

 The preferred location for administration is the prescribing physician’s office, especially for high risk patients  AIT must be initiated and monitored by an allergist  Pts. may receive AIT at another health care facility if the physician and the staff are equipped to recognize and manage systemic reactions  Full, clear, detailed immunotherapy schedule must be present  Constant, uniform labeling system for extracts, dilutions and vials  Procedures to avoid clerical/nursing errors (i.e. pt. photo ID) (file by DOB)

Issues in College Health Setting  Information needed from allergist  Policies and procedures that increase safety  Immediate and delayed reactions  Recognition and treatment of anaphylaxis  Preparedness plan for educating staff  Information needed from allergist  Policies and procedures that increase safety  Immediate and delayed reactions  Recognition and treatment of anaphylaxis  Preparedness plan for educating staff

Immunotherapy Safety  Incidence of fatalities has not changed much in the last 30 years in the US  From fatal reactions occurred at a rate of 1 per 2.5 million injections  Most occur during maintenance phase or “rush” schedule  Poorly controlled asthmatics at greatest risk  Many deaths associated with a delay in administering epinephrine or not giving it at all  Incidence of fatalities has not changed much in the last 30 years in the US  From fatal reactions occurred at a rate of 1 per 2.5 million injections  Most occur during maintenance phase or “rush” schedule  Poorly controlled asthmatics at greatest risk  Many deaths associated with a delay in administering epinephrine or not giving it at all

Preparedness of health service  Established medical protocols and treatment records  Stock and maintain equipment/supplies  Physicians and staff maintain “clinical proficiency” in anaphylaxis recognition and management  Consideration of drills tailored to assess skills, response, and preparedness of office staff  Tailor drill to consider access to local EMS- response times vary by location  Established medical protocols and treatment records  Stock and maintain equipment/supplies  Physicians and staff maintain “clinical proficiency” in anaphylaxis recognition and management  Consideration of drills tailored to assess skills, response, and preparedness of office staff  Tailor drill to consider access to local EMS- response times vary by location

Patient Responsibility  Patient must wait minutes in office  Those with prior systemic or delayed reactions should wait longer  Compliance with injection schedule  Report any reactions to PCP and allergist  Epi-Pen kits for self treatment  Patient must wait minutes in office  Those with prior systemic or delayed reactions should wait longer  Compliance with injection schedule  Report any reactions to PCP and allergist  Epi-Pen kits for self treatment

Local Reactions Are Common Redness, swelling, warmth at site  Large, local, delayed reactions do not predict the development of severe systemic reactions  Local reactions may affect dosing schedule Redness, swelling, warmth at site  Large, local, delayed reactions do not predict the development of severe systemic reactions  Local reactions may affect dosing schedule Measurement Scales  Differ between allergist  Measure in mm  Compare to coin  Grade  Length of reaction

Options for treating local reaction Don’t need MD order  Change needle  Ice to site  Hydrocortisone to site  Benedryl spray to site Don’t need MD order  Change needle  Ice to site  Hydrocortisone to site  Benedryl spray to site Do need MD order  Non sedating antihistamine prior to injection  Benedryl rinse  Epi rinse  Lowering dose  Halt dose increase during pollen season

Benadryl or Epi Rinse Instructions  Draw Benadryl into syringe  Pull plunger of syringe back until the entire barrel of syringe has been coated with Benadryl  Return Benadryl to original Benadryl container  Fill syringe with appropriate dose  Draw Benadryl into syringe  Pull plunger of syringe back until the entire barrel of syringe has been coated with Benadryl  Return Benadryl to original Benadryl container  Fill syringe with appropriate dose

Systemic Reactions  Incidence of systemic reactions ranges from 0.05% to 3.2% of injection  Most occur during maintenance phase  Poorly controlled asthmatics at greatest risk  Many deaths are associated with a delay in administering epinephrine or not giving at all  Risk factors include:  Dosing errors  Symptomatic asthma  High degree of allergy hypersensitivity  Use of beta blockers/ACE-I  New vials  Injections during the allergy season  Dosing protocols (rush regimens)  Incidence of systemic reactions ranges from 0.05% to 3.2% of injection  Most occur during maintenance phase  Poorly controlled asthmatics at greatest risk  Many deaths are associated with a delay in administering epinephrine or not giving at all  Risk factors include:  Dosing errors  Symptomatic asthma  High degree of allergy hypersensitivity  Use of beta blockers/ACE-I  New vials  Injections during the allergy season  Dosing protocols (rush regimens)

Symptoms of Systemic Reactions  Any allergic symptom that occurs at a location other than the site of the injection  Chest congestion or wheezing  Angioedema-swelling of lips,tongue, nose, or throat  Urticaria, itching, rash at any other site  Abdominal cramping, nausea, vomiting  Light-headedness, headache  Feeling of impending doom, decrease in level of consciousness  Any allergic symptom that occurs at a location other than the site of the injection  Chest congestion or wheezing  Angioedema-swelling of lips,tongue, nose, or throat  Urticaria, itching, rash at any other site  Abdominal cramping, nausea, vomiting  Light-headedness, headache  Feeling of impending doom, decrease in level of consciousness

Anaphylaxis: potentially deadly allergic reaction that is rapid in onset, most commonly triggered by food, medication or insect sting  Most common: ATB (penicillin, cephalosorins) Food (nuts, cows milk, seafood) Insect  Age trends:  Adolescents/young adults: foods  Middle age: venom  Older adults: medications  Most common: ATB (penicillin, cephalosorins) Food (nuts, cows milk, seafood) Insect  Age trends:  Adolescents/young adults: foods  Middle age: venom  Older adults: medications

Recognition of Anaphylaxis for college health, this isn’t just for allergy injections!  Most reactions (1/2 – 1/3) occur in minutes of vaccine 10% 30 – 60 min (asthma with multiple injections Medication min Insect sting min Foods 25 – 35 min Late phase (8-12 hrs) reactions possible  Prompt recognition of potentially life threatening reactions by staff and patients  Urticaria/angioedema are the most common initial symptoms--but they may be absent or delayed  Most reactions (1/2 – 1/3) occur in minutes of vaccine 10% 30 – 60 min (asthma with multiple injections Medication min Insect sting min Foods 25 – 35 min Late phase (8-12 hrs) reactions possible  Prompt recognition of potentially life threatening reactions by staff and patients  Urticaria/angioedema are the most common initial symptoms--but they may be absent or delayed

Most Common Signs and Symptoms  Skin: flushing, itching, urticaria: 90%  Upper and lower airway signs: cough, wheezing, dyspnea, change in voice quality, feeling of throat closing: 70%  GI symptoms: nausea, vomiting, diarrhea, crampy abdominal pain: 40%  Skin: flushing, itching, urticaria: 90%  Upper and lower airway signs: cough, wheezing, dyspnea, change in voice quality, feeling of throat closing: 70%  GI symptoms: nausea, vomiting, diarrhea, crampy abdominal pain: 40%

5 Most Common Factors in Fatal Reactions  Uncontrolled asthma (62%)  Prior history of systemic reaction (53)  Injections during peak pollen season (43%)  Delay/failure in epi treatment (43%)  Allergy injection given IM instead of SQ or dosing error (17%) Also: upright posture  Uncontrolled asthma (62%)  Prior history of systemic reaction (53)  Injections during peak pollen season (43%)  Delay/failure in epi treatment (43%)  Allergy injection given IM instead of SQ or dosing error (17%) Also: upright posture

Recommended Equipment  Stethoscope, BP cuff  Tourniquet, large bore IV needles, IV set-up  Aqueous epinephrine 1:1000  O2 and mask/nasal cannula  Oral airway  Treatment log  Stethoscope, BP cuff  Tourniquet, large bore IV needles, IV set-up  Aqueous epinephrine 1:1000  O2 and mask/nasal cannula  Oral airway  Treatment log  Diphenhydramine (oral and injection)  Albuterol nebulized  Glucagon

Immediate Intervention  Assess ABC’s  Administer epinephrine ASAP! There is no contraindication  Fatalities usually result from delayed administration of epinephrine--with respiratory, and cardiovascular complications  Subsequent care based on response to epinephrine  Assess ABC’s  Administer epinephrine ASAP! There is no contraindication  Fatalities usually result from delayed administration of epinephrine--with respiratory, and cardiovascular complications  Subsequent care based on response to epinephrine

Epinephrine  1:1000 dilution, 0.3 mg. dose administered IM or SQ q5 minutes as needed to control BP and other symptoms  Tourniquet above injection site  Pt can use their Epi-pen  Effect of epi can be blunted by beta-blockers, with severe, prolonged sx including bronchospasm, bradycardia, and hypotension  Glucagon can be used to reverse beta blockers  1:1000 dilution, 0.3 mg. dose administered IM or SQ q5 minutes as needed to control BP and other symptoms  Tourniquet above injection site  Pt can use their Epi-pen  Effect of epi can be blunted by beta-blockers, with severe, prolonged sx including bronchospasm, bradycardia, and hypotension  Glucagon can be used to reverse beta blockers

IM vs. SQ Epinephrine  Both routes of injection appear in the literature  IM injections into the thigh have been reported to provide more rapid absorption and higher plasma levels than IM or SQ injections into the arm.  Studies directly comparing different routes have not been done  Both routes of injection appear in the literature  IM injections into the thigh have been reported to provide more rapid absorption and higher plasma levels than IM or SQ injections into the arm.  Studies directly comparing different routes have not been done

Interventions continued…  Establish/maintain airway  Give O2/check pulse ox  IV access, hang IV fluids with NS  Consider:  Diphenhydramine mg. IM  Albuterol nebulized  Transfer to ED  Establish/maintain airway  Give O2/check pulse ox  IV access, hang IV fluids with NS  Consider:  Diphenhydramine mg. IM  Albuterol nebulized  Transfer to ED

Measures to reduce dosing errors  Educate staff administering  Standardize forms & protocols  Multiple identity checks: name/DOB  One patient in “shot” room  Avoid distractions to staff  Patient education about systemic reactions  Educate staff administering  Standardize forms & protocols  Multiple identity checks: name/DOB  One patient in “shot” room  Avoid distractions to staff  Patient education about systemic reactions

Increase administration safety  Detailed instructions from allergist  Develop own step by step process for giving injections  Standardize forms to document injections  Standardize treatment for systemic reaction  Agreement form for student compliance  All staff competency and mock systemic reaction drill  Review of health status before injections  Detailed instructions from allergist  Develop own step by step process for giving injections  Standardize forms to document injections  Standardize treatment for systemic reaction  Agreement form for student compliance  All staff competency and mock systemic reaction drill  Review of health status before injections

Review Health Status Before Injections (why you don’t draw injection first)  Current asthma symptoms, ? Measure peak flow  Current allergy symptoms and medication use  New medications (beta blockers, ACE-I)  Delayed reactions to previous injections  Compliance with injection schedule  New illness (fever), pregnancy  Consultation with allergist as needed  Current asthma symptoms, ? Measure peak flow  Current allergy symptoms and medication use  New medications (beta blockers, ACE-I)  Delayed reactions to previous injections  Compliance with injection schedule  New illness (fever), pregnancy  Consultation with allergist as needed

References  Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility, ACAAI, October  Rank MA, Li JTC. Allergen Immunotherapy. Mayo Clin Proc. 2007;82(9):  Stokes JR, Casale TB. Allergy Immunotherapy for Primary Care Physicians. AJM. 2006;119(10):  Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis:an updated practice parameter. J Allergy Clin Immunology 2005;115:S  Li JT, Lockey IL, Bernstein JM, et al. Allergen immunotherapy: a practice parameter. Ann Allergy, Asthma & Immunology.2003;90:1-40.  Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility, ACAAI, October  Rank MA, Li JTC. Allergen Immunotherapy. Mayo Clin Proc. 2007;82(9):  Stokes JR, Casale TB. Allergy Immunotherapy for Primary Care Physicians. AJM. 2006;119(10):  Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis:an updated practice parameter. J Allergy Clin Immunology 2005;115:S  Li JT, Lockey IL, Bernstein JM, et al. Allergen immunotherapy: a practice parameter. Ann Allergy, Asthma & Immunology.2003;90:1-40.