Allergy Immunotherapy in the College Health Setting New York State College Health Association 2010 ANNUAL MEETING Mary Madsen RN – BC Assistant Director,

Allergy Immunotherapy in the College Health SettingAllergy Immunotherapy in the College Health Setting

New York State College Health Association 2010 ANNUAL MEETING

Mary Madsen RN – BCAssistant Director, Clinical OperationsUniversity Health ServiceUniversity of Rochester

New York State College Health Association 2010 ANNUAL MEETING

Mary Madsen RN – BCAssistant Director, Clinical OperationsUniversity Health ServiceUniversity of Rochester

Allergies: immune system overreacts by producing antibodies called Immunglobulin E (IGE) these travel to cells and release chemicals, causing the

allergic reactions

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)

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 SettingIssues 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 SafetyImmunotherapy 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

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

Preparedness of health servicePreparedness 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 ResponsibilityPatient 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

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

Local Reactions Are CommonLocal 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 1+ - 4+ Length of reaction

Measurement Scales Differ between

allergist Measure in mm Compare to coin Grade 1+ - 4+ Length of reaction

Options for treating local 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

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 InstructionsBenadryl 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 ReactionsSystemic 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 ReactionsSymptoms 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

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 Anaphylaxisfor college health, this isn’t just for allergy injections!

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

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

Most Common Signs and SymptomsMost 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

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 EquipmentRecommended 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

Diphenhydramine (oral and injection)

Albuterol nebulized Glucagon

Immediate InterventionImmediate 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

EpinephrineEpinephrine

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 EpinephrineIM 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…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

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

Measures to reduce dosing errorsMeasures 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 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)

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

ReferencesReferences

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.

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.