Lancaster Physician Summer 2019 - 31

SUMMER 2019

anything besides prophylactic exercise in the
last 24 hours, or has felt like they should have
used it, should not get a shot. Patients should
be screened before the injection for changes in
medications, illness, asthma flare, and problems
with their last injection. Identity of the patient
should be checked x3 (for example picture,
birthdate, and name). Medications such as
beta blockers, while not shown to increase
the risk of reactions in most studies, may, in
theory, prevent patients from responding as
well to epinephrine during a reaction because
they use similar receptors. ACE inhibitors, in
venom patients especially, may be a risk factor
for reaction severity; more study is needed. The
treatment for anaphylaxis, or systemic allergic
reaction to an allergy shot, is the same as that
for anaphylaxis to other causes-epinephrine.
Notice I did not say Benadryl or steroids or
your albuterol inhaler? These are adjuncts.
Antihistamines can take an hour to kick in;
steroids may take several hours. Because of the
risk of allergic reaction to your allergy injection,
there is a 30-minute recommended mandatory
in-our-office wait period after a shot is given.

The majority of reactions occur within 20 to
30 minutes. Fortunately, systemic reactions
are rare. The most common side effect is local
itching or swelling about the size of a bug bite.
The injections are subcutaneous on the lateral
side or back of the upper arm. Even my little
drama queen tolerates them, behaving well
with a combination of threats and bribes; she
doesn't even feel them on most days. Most
children, even those anxious about shots, do
well after a few injections after they realize
they are not like the intramuscular vaccines
they have received previously.
I would like to mention sublingual immunotherapy, a newer alternative for some select
patients. It consists of a dissolving tablet under
the tongue taken daily for several months
preceding the pollen season or year-round.
The most common side effect is itchy mouth,
and risk of systemic reaction is even lower than
with subcutaneous immunotherapy. Sublingual
immunotherapy is available for grass pollen,
ragweed, and dust mites, and cat allergies were
also studied well. Limitations are the cost and

getting insurance approval, which I have found
difficult. It is very rare for me to have pollen
patients in the northeast that do not suffer from
multiple allergens, especially tree pollens. Studies
in the U.S. have not favored multiple allergen
sublingual immunotherapy as effective, and
products that are sold or marketed on a cashand-carry basis do not have proven efficacy or
FDA approval.
Subcutaneous allergy immunotherapy is a
long-term therapy-it does not give instant
relief. I have found personally that the weekly
build-up schedule is difficult to do-like adding
another extracurricular activity each week. We
are not the most compliant patients. However,
after a year, while my daughter still has some
bad days where I have to sit on her to pop in eye
drops, she has not been to the nurse once. Her
oral allergy syndrome with apples has improved,
and her allergy symptoms are significantly better
and medication use is down. I would absolutely
initiate them again for my daughter, and I do
love her most days.

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LANCASTER

PHYSICIAN

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Lancaster Physician Summer 2019

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