Q:

4/29/2013
Question regarding adjustment of immunotherapy in patients who are receiving their maintenance dose injections and need to change manufacturer.

How would you personally adjust the maintenance dose for patients receiving monthly maintenance injections at a different allergist with DIFFERENT manufacturer and come to you to continue shots? The 3rd update, 2010 to IT practice parameters states that "the physician can consider decreasing the dose by 50% to 90% of the previous dose. For changes in manufacturer and nonstandardized extracts, a greater decrease in dose might be necessary." This is vague.

This situation comes up when we have a patient transfer over to us from another allergist. Also we are considering switching manufacturers in our practice.

I imagine for the non standardized pollens etc that variability of maintenance dose can vary 100 fold or some unknown amount? When I discussed with Greer and ALK manufacturers they felt a buildup from 0.1, 0.3, 0.5 of new maintenance vial would be sufficient. This is actually what we do for the SAME manufacturer, with different lot. Exactly how far back do you go to buildup when a change in manufacturer and given that you have the previous allergists' recipe of serum components and are trying to keep it the same. Ie oak tree ALK 0.1 cc of 1/10 in 5 cc vial, changing to 0.1 cc of 1/10 in 5cc vial of Greer... How much buildup do you use in this case?

I saw a similar question but did not see your answer for a different manufacturer as described above. Thank you.

A:

Thank you for your inquiry.

Unfortunately, there is no standard accepted model to follow in this situation, and the Practice Parameter information that you quoted is one way to approach it. The manufacturer of each extract does have suggestions for you to follow. For example, if you are using one manufacturer’s extract and the physician transferring the patient used another manufacturer’s extract, you can receive suggestions from the manufacturer of your extract. We will normally do this. That is, we may follow the suggestions of the manufacturer of the extract that we employ.

In addition, on occasion, I have dropped back two dilutions. Much depends on when the patient received his/her last dose, what the initial skin test reactions looked like, if they have had any previous reactions, et cetera.

All of the suggestions above (that is, to call your manufacturer, drop back two dilutions, or follow the suggestions of the Parameters) are acceptable choices.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.




AAAAI - American Academy of Allergy Asthma & Immunology