Systemic reactions to subcutaneous immunotherapy

The  2010  WAO  Grading  System  is  a  useful  tool  for  accessing  SR  severity.  SR  to  SCIT  with  airborne  allergens  are  rare  and  all  of  our  reacCons  were  grade  1  or  

2.  None  of  the  commonly  implicated  risk  factors  was  idenCfied  in  our  paCents.    A  large  scale  study  is  needed  to  perform  comparaCve  analysis  and  to  clarify  

the  best  surveillance  and  treatment  of  SR  to  SCIT.  

A  first  characterizaCon  according  to  WAO's  grading  system  

Santos,  Natacha;  Pereira,  Ana  Margarida;  Silva,  Rui;  Torres  da  Costa,  José;  Plácido,  José  Luís  Serviço  de  Imunoalergologia,  Centro  Hospitalar  São  João,  E.P.E.,  Porto,  Portugal  

Systemic   reacCons   (SR)   to   subcutaneous   immunotherapy   (SCIT)   are   unusual   but  

potenCally  severe.    

Poorly  controlled  asthma,  large  local  reacCons,  administraCon  during  pollen  season  

and   dose   error   are   the   more   implicated   risk   factors,   but   studies   have   been  

hampered  due  to  the  variety  of  previously  exisCng  classificaCons.    

The  aim  of  our  study  is  to  characterize  SR  to  SCIT  with  airborne  allergens  occurring  

in  our  clinic  from  January  2008  to  June  2010  and  to  classify  them  according  to  the  

WAO  Subcutaneous  Immunotherapy  Systemic  ReacCon  Grading  System1.    

1L.  Cox,  D.  Larenas-­‐Linnemann,  R.  F.  Lockey,  G.  Passalacqua;  Speaking  the  same  language:  The  World  Allergy  OrganizaCon  Subcutaneous  Immunotherapy  Systemic  ReacCon  Grading  System;  J  Allergy  Clin  Immunol  2010;125:569-­‐74.  2J.  E.  Alvarez-­‐Cuesta,  J.  Bousquet,  G.  W.  Canonica,  S.  R.  Durham,  H.  J.  Malling,  E.  Valovirta.  Standards  for  pracCcal  allergen-­‐specific  immunotherapy.  Ann  Allergy  Asthma  Immunol.  Allergy  2006:  61  (Suppl.  82):  1–20  

Cross-­‐secConal   study   with   data   collected   from   a   paCent's  

immunotherapy   record   form.   PaCent   selecCon   and   SCIT  

administraCon  followed  EAACI  recommendaCons2.    

During   the   study   period,   19398   SCIT   to   airborne   allergens  

were   administered,   and   immediate   reacCons   (beginning   <  

30min),  as  well  as  late  reacCons,  were  recorded.    

SR  occurred   in  13  paCents,  ♂8:5♀,  median  age  of  25  years-­‐

old  (6-­‐89),  in  a  total  of  20  SR  (0,1%  of  all  administraCons).  

Allergic  disease  Immunotherapy   Systemic  reac6ons  

Composi6on   Formula6on   Administra6on   Phase   Time   Manifesta6on   WAO  

RhiniCs   Grass   Polymerized   Rush   InducCon   Immediate   Rhinorrhea   1z  RhiniCs   Mites   Depot   Classical   InducCon   Immediate   Rhinorrhea   1z  RhiniCs   Mites   Depot   Classical   InducCon   Immediate   Rhinorrhea   1z  

RhiniCs  +  Asthma   Mites   Polymerized   Classical   InducCon  InducCon  

Late  Immediate  

Rhinorrhea  ConjunCval  pruritus  

1z  1z  

RhiniCs   Mites   Depot   Classical  InducCon  InducCon  InducCon  

Late  Immediate  Late  

Rhinorrhea  Rhinorrhea  Rhinorrhea  

1z  1z  1z  

RhiniCs   Mites   Polymerized   Classical   InducCon   Late   Oropharingeal  pruritus   1z  

RhiniCs   Mites   Polymerized   Classical   Maintenance  Maintenance  

Immediate  Late  

Rhinorrhea  Rhinorrhea  

1z  1z  

RhiniCs  +  Asthma   Grass   Polymerized   Rush   Maintenance   Late   Sneezing   1z  

RhiniCs  +  Asthma   Mites   Polymerized   Rush  InducCon  InducCon  InducCon  

Late  Late  Late  

Asthma  Asthma  Asthma  

2z  2z  2z  

RhiniCs  +  Asthma   Mites   Polymerized   Classical   InducCon   Late   Asthma   2z  

RhiniCs  +  Asthma   Mites   Polymerized   Rush   InducCon  InducCon  

Late  Late  

Rhinorrhea  -­‐>  Asthma  Nasal  congesCon  

2z  1z  

RhiniCs   Grass   Polymerized   Rush   InducCon   Late   Generalized  erythema    -­‐>  Wheezing   2z  

RhiniCs   Mites   Polymerized   Rush   Maintenance   Late    Generalized  erythema      -­‐>  Rhinorrhea    -­‐>  Shortness  of  breath  

2d  

There  were  14  (70%)  late  reacCons,  with  5  of  them  occurring  aner  3  hours  (maximum  48  hours  aner).  Only  2  paCents  had  

previous  local  reacCons,  both  with  wheals  <  5cm.  All  3  paCents  with  SCIT  to  grass  had  the  SR  out  of  the  pollen  season.  

Table  1.  CharacterizaCon  of  paCents  and  systemic  reacCons