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Dana V. Wallace, MD Assistant Clinical Professor Nova Southeastern University Davie, Florida

Forms & Templates for. Allergen Immunotherapy. Dana V. Wallace, MD Assistant Clinical Professor Nova Southeastern University Davie, Florida drdanawallace@gmail.com. ANAPHYLAXIS IN THE OFFICE ALLERGIST and Staff BE PREPARED. Templates and Forms ARE IMPORTANT!. Templates & Forms for SIT.

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Dana V. Wallace, MD Assistant Clinical Professor Nova Southeastern University Davie, Florida

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  1. Forms & Templates for Allergen Immunotherapy Dana V. Wallace, MDAssistant Clinical ProfessorNova Southeastern UniversityDavie, Florida drdanawallace@gmail.com

  2. ANAPHYLAXIS IN THE OFFICEALLERGIST and Staff BE PREPARED Templates and Forms ARE IMPORTANT!

  3. Templates & Forms for SIT • Cox, L., H. Nelson, et al. "Allergen immunotherapy: a practice parameter third update." J Allergy Clin Immunol127(1 Suppl): S1-55. • http://www.jacionline.org/article/PIIS0091674910015034/addons[jacionline] • www.acaai.org • (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy) • Kalier, M., Lockey, R., eds. Clinical Allergy and Immunology Series, 4th Edition • www.drdanawallace.com

  4. Discussing SCIT Treatment Option www.drdanawallace.com

  5. SLIT Patient Info (Part 1)

  6. SLIT Patient Info (Part 2)

  7. SLIT Patient Info (Part 3)

  8. SLIT Side Effects

  9. Allergy Immunotherapy Consent process should discuss: • Treatment and alternatives • Potential benefit • Potential risks, giving frequency of adverse events, including death • Cost associated and coverage options • Anticipated duration of Tx • Office policies that affect Tx, e.g. waiting time, missed AIs Based on 2011 Immunotherapy PP

  10. Consent to Allergen Immunotherapy www.acaai.org

  11. CONSENT FORMS TO CONSIDER www.drdanawallace.com • Allergy testing & immunotherapy • Permission to treat a minor • Consent to take allergy vaccine out of office to another MD for administration • Consent from remote MD agreeing to administer AI • Privacy form to authorize info to specific people- e.g. child custody

  12. Consent to take Allergen Extract Sets to another office www.acaai.org

  13. Cross-reacting Allergens jacionline

  14. Recommended Documentation SCIT Prescription (Rx) Forms jacionline • Purpose: • To define the contents of the allergen immunotherapy extract in enough detail that it could be precisely duplicated • Patient information: • Name, chart number (if applicable), birth date, telephone number (home/mobile), email, & picture • Preparation information: • Name of person (& signature) preparing the allergen immunotherapy extract & date prepared • Vial name, by allergens included (e.g., Trees, Grass or abbreviations (e.g., T, G, with legend)

  15. Recommended Documentation SCIT Prescription (Rx) Forms jacionline • Allergen immunotherapy extract content information for each allergen: • Common name or genus and species • Concentration of available manufacturer’s extract • Volume of manufacturer’s extract to add to achieve the projected effective concentration • Calculate by dividing the projected effective concentration by the concentration of available manufacturer’s extract times the total volume • Extract manufacturer & lot number, expiration date • Same detail for all mixes • Vial expiration date should not exceed of any of the individual components

  16. SCIT Prescription Form jacionline

  17. SCIT Prescription Form-completed jacionline

  18. IMMUNOTHERAPY RX FORM MODIFIED BY DANA WALLACE,MD www.acaai.org (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)

  19. Labels for allergen immunotherapy extracts jacionline • Each vial must have appropriate patient identifiers, e.g., name, number, DOB, picture • Contents, e.g, T, G, M, Df, D, etc. • The dilution from the maintenance concentrate (vol/vol) using color, numbers, letters • Expiration date of individual vial

  20. Allergy Extract Vial Dilution & Labeling www.acaai.org

  21. Allergy Extract Vial Dilution & Labeling www.acaai.org

  22. Vial Labels www.acaai.org

  23. Weekly Build-up Therapy jacionline

  24. Cluster SCIT Schedule jacionline

  25. SCIT Rush Immunotherapy Schedule www.acaai.org

  26. SLIT Proposed Schedules

  27. SCIT Administration Record jacionline • List info in separate columns • Date of injection • Arm administered • Delivered volume in mm • Currently on antihistamine (desirable) • Projected build-up schedule • Description of any reaction (details may appear on separate sheet • Peak flow- pre and post SCIT may be included

  28. ALLERGY INJECTION ADMIN. FORM www.acaai.org (ACAAI > Members > Practice Resources > Skin Testing & Immunotherapy)

  29. SCIT Administration Record www.acaai.org

  30. Health Screen Form (Pre SCIT) jacionline • Patient identifiers, date, baseline peak flow & BP, if advised to use antihistamines with SCIT • Records status of: • Asthma control, consider standardized instrument and Peak Flow pre and post • Beta-blocker use • Pregnancy or other recent health care status, including recent infection or allergy/asthma flare • Previous adverse reaction to SCIT • Consider BP measurement

  31. Health Screen Form jacionline

  32. PRE-INJECTION HEALTH SCREEN www.acaai.org

  33. Preparing your office staff for ANAPHYLAXIS

  34. ANAPHYLAXIS CART

  35. Supplies and Equipment for Anaphylaxis Treatment in office “NECESSARY” • Stethoscope and sphygmomanometer • *Epinephrine 1:1000 • Oxygen • IV Fluids • Tourniquets, syringes, hypodermic needles, large-bore needles “CONSIDER HAVING” • One-way valve facemask • Diphenhydramine inj. • Corticosteroids inj. “MAYBE” • Vasopressor (Dopamine) • Glucagon • Automatic defibrillator • Oral airway * Required 2011 JTF Anaphylaxis PP

  36. ANAPHPYLAXIS CART INVENTORY AND UPDATE LIST www.acaai.org 2005

  37. ANAPHYLAXIS TREATMENT www.drdanawallace.com

  38. Patient Name_______________________TABLE OF ANAPHYLAXIS DRUGS www.drdanawallace.com

  39. Anaphylaxis Simple TX Plan

  40. 0.01 POST AN ANAPHYLAXIS PROTOCOL AND/OR ALGORITHM (in visible location )

  41. ANAPHYLAXIS TX RECORD www.acaai.org

  42. WAO Grading System for SCIT Systemic Reactions: GRADE 1- one organ system • Cutaneous • Urticaria, generalized pruritus, flushing, or sensation of heat or warmth or • Angioedema (not laryngeal, tongue, or uvula) OR • Respiratory • Rhinitis symptoms (e.g., sneezing, rhinorrhea, nasal pruritus and/or nasal congestion or • Throat clearing (itchy throat) or • Cough perceived to originate in the upper airway mot eh lung, larynx, or trachea Or • Conjunctival: erythema, tearing, or pruritus • Other: nausea, metallic taste, or headache

  43. WAO Grading System for SCIT Systemic Reactions: GRADE 2 • Symptoms/signs of more than one organ system present or • Lower respiratory • Asthma: cough, wheezing, SOB (e.g. < than 40% PEF or FEV1 , responding to inhaled bronchodilator) or • Gastrointestinal • Abdominal cramps, vomiting, or diarrhea Or Other: uterine cramps Patients may describe a feeling of doom Might include any of the symptoms listed in grade 1

  44. WAO Grading System for SCIT Systemic Reactions: GRADE 3 • Lower respiratory • Asthma (e.g. 40% PEF or FEV1 ) or • Upper respiratory • Laryngeal, uvula, or tongue edema with or without stridor Note: Might include any of the symptoms listed in grade 1 and 2 Patients may describe a feeling of doom

  45. WAO Grading System for SCIT Systemic Reactions: GRADE 4 • Lower or upper respiratory • Respiratory failure with or without loss of consciousness or • Cardiovascular • Hypotension with or without loss of consciousness Note: Might include any of the symptoms listed in grade 1, 2, and 3 Adults may describe a feeling of doom

  46. WAO Grading System for SCIT Systemic Reactions: GRADE 5 • Death [We Must Prevent]

  47. Thank You • DANA WALLACE, MD • drdanawallace@gmail.com • www.drdanawallace.com • MEDICALPROFESSIONAL (USER NAME) • Allergy (PASSWORD)

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