Allergy Immunotherapy in the College Health Setting

1. 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

2. 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

3. 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)

4. 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

5. Immunotherapy Safety • Incidence of fatalities has not changed much in the last 30 years in the US • From 1990-2001 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

6. 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

7. Patient Responsibility • Patient must wait 20-30 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

8. 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 1+ - 4+ Length of reaction Local Reactions Are Common

9. 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 Options for treating local reaction

10. 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

12. 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)

13. 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

14. 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

15. Recognition of Anaphylaxisfor college health, this isn’t just for allergy injections! • Most reactions (1/2 – 1/3) occur in 20-30 minutes of vaccine 10% 30 – 60 min (asthma with multiple injections Medication 10-20 min Insect sting 10-15 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

16. 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%

17. 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

18. 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 Recommended Equipment

19. 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

20. 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

21. 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

22. Interventions continued… • Establish/maintain airway • Give O2/check pulse ox • IV access, hang IV fluids with NS • Consider: • Diphenhydramine 25-50 mg. IM • Albuterol nebulized • Transfer to ED

23. 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

24. 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

25. 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

26. References • Position Statement on the Administration of Immunotherapy Outside of the Prescribing Allergist Facility, ACAAI, October 1997. • Rank MA, Li JTC. Allergen Immunotherapy. Mayo Clin Proc. 2007;82(9):1119-1123. • Stokes JR, Casale TB. Allergy Immunotherapy for Primary Care Physicians. AJM. 2006;119(10):820-823. • Lieberman P, Kemp SF, Oppenheimer J, et al. The diagnosis and management of anaphylaxis:an updated practice parameter. J Allergy Clin Immunology 2005;115:S483-523. • Li JT, Lockey IL, Bernstein JM, et al. Allergen immunotherapy: a practice parameter. Ann Allergy, Asthma & Immunology.2003;90:1-40.