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covering up the symptoms like most medications. It is a good choice
especially for those who do not tolerate medications, get relief from
medications, or like to take medications. There are no age limitations
for immunotherapy, but most of us find it difficult to give weekly
shots to toddlers, and elderly patients with multiple health issues and
medication use may not be the best candidates unless other options
are exhausted.
Like a vaccine, doses of allergy immunotherapy stimulate the immune
system to develop tolerance to the allergen. There are two phases:
1. The build-up phase usually lasts less than a year and starts as a diluted
extract with potency slowly increased on a regular schedule, often weekly.
2. The maintenance phase involves the highest concentration vial, which is
continued, usually every 4 weeks for several years. Most people, after several
years on the maintenance vial, are able to discontinue allergy immunotherapy
with benefits lasting years after injections are discontinued.
Allergy immunotherapy is effective and indicated for a range of
allergies and conditions from the treatment of allergic rhinitis to
environmental allergies like pollen, dust mites, molds, and animals
to allergic asthma, allergic conjunctivitis (eye allergy) and even atopic
dermatitis. Another allergen that is very important and should not be
forgotten is stinging insect allergy (bees, wasps, hornets, and yellow
jackets as well as fire ants in endemic areas). This latter indication is
critical; while deaths from insect stings are rare, they happen. Fortunately,
they are preventable, with immunotherapy reducing patients' risk to a
level close to that of the general population. That movie, "My Girl," in
which a child dies after bee stings, should have had a different ending.

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Allergy immunotherapy is NOT indicated for food allergies, although
several exciting developments in the treatment of food allergies are
likely coming soon as they are in the final stages of FDA approval. The
minor exception would be oral allergy syndrome, in which patients
get itchy mouth or throat after eating fresh, raw fruits and vegetables
(cooked produce usually doesn't cause a problem for these people).
The mechanism involves structural similarity to pollen-your body
reacts as though you grabbed a handful of tree pollen and stuffed it in
your mouth. This issue occurs in about 10 percent of allergic patients.
Systemic reaction is rare, as patients are not truly allergic to the food,
and after the produce is mushed down and digested or cooked, it
doesn't resemble pollen anymore. Although allergy immunotherapy
has improved oral allergy syndrome in some studies about 50 percent
of the time, I do not recommend it for this reason alone if no other
symptoms are present. My daughter developed oral allergy syndrome
with apples and mulberries. We avoid mulberries now. Apples are harder
to avoid, as they are often the go-to snack for elementary school kids.

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While risks from immunotherapy are low and chance of death is
so low that you are more likely to get struck by lightning, injections
need to be given in a doctor's office. One of the biggest risk factors for
adverse outcomes to allergy immunotherapy is uncontrolled asthma.
Anyone who is having an asthma flare, has used their albuterol for

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Lancaster Physician Summer 2019

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