Q:

2/3/2012
As a service to our employees we administer allergy injections to our employees who provide their own serum. We follow the guidelines provided by their Allergist. My question(s): Is the color coding on the vials universal? Do you have a list of what strength each color indicates? Thank you.

A:

Thank you for your inquiry.

The following color coding system has been recommended by our national Allergy-Immunology society guidelines. The most dilute vaccine being silver, and the most concentrated (strongest) being red. However I cannot tell you whether all allergists employ this system, and physicians from other specialties eg, otolaryngologists, also prescribe allergy injections.

Therefore if there is any question regarding the strength of an extract or the progression of the injections the prescribing physician should be consulted.

All the vials in the treatment set are numbered and/or color coded in the following manner:
• RED Maintenance Concentrate 1:1 vol/vol #1
• YELLOW 10 fold dilution 1:10 vol/vol #2
• BLUE 100 fold dilution 1:100 vol/vol #3
• GREEN 1000 fold dilution 1:1000 vol/vol #4
• SILVER 10,000 fold dilution 1:10,000 vol/vol #5

Sincerely,
Phil Lieberman MD

Follow-up inquiry:
I thank you for your quick reply. I am writing the SOP for allergy injections for our company. I have been assigned the roll of SME (Subject Matter Expert) for allergy injections. Basically, I am the go-to person for allergy injections. I have been doing patient care and allergy injections for 20+ years. However, I am finding that each allergy associate in the Indianapolis area has their own set of rules and recommendations.  Do you have the latest and greatest recommended SOP or procedure for giving allergy injections?

Mostly, I need to know:
Where exactly do you place the needle?
Do you or do you not have to aspirate?
How long does the patient need to stay in the waiting room?
Can the patient receive a flu shot on the same day as their allergy injection? If not, why?
Is it required for a patient to bring an Epi Pen or Benadryl with them?

I would like to have the specifics from the Expert. If I have to go back to the website to send you this question, let me know. Thank you so much in advance.

Thank you for your follow-up inquiry.

Unfortunately many of the questions you asked are not answerable.  There have been no studies designed to address these issues and therefore they are left to the discretion of the allergist administering the shots. Since there are no standards per se, I will discuss with you what we do in our office, and refer you to previous questions that have been submitted to the Ask the Expert website in this regard.

We prefer the needle to be placed approximately halfway between the shoulder and the elbow towards the back of the arm.

We usually recommend aspiration. 

The only question that you asked that has a standard consensus recommendation is the time that the patient should remain in the waiting room. It is a consensus that this should be 30 minutes. The patient can receive a flu shot on the same day they receive their allergy injection.

Different allergists have different opinions as to whether or not a patient should bring an automatic epinephrine injector and/or an antihistamine with them. We do not require such in our office. There is no standardized consensus in this regard, and a recent survey illustrated that there is wide diversity amongst allergists as to this practice. Wherever allergy injections are given epinephrine must be available. The only reason for a patient to have an epinephrine injector with them is related to the fact that they may need an injection after they leave the office since some reactions do occur after 30 minutes.  As noted, a recent survey indicated that allergists differ greatly in their recommendation in this regard. If you feel that you must have a decision about this procedure, your best bet would be to contact each individual allergist who supplies extract if they do not offer the information to you when the patient is referred for injections.

In regards specifically to your question about where on the arm the allergy shot should be placed, I have copied below our response to a similar previous inquiry. There is link to a website which will be very helpful to you regarding other questions you may have with regard to technique of administration. Our response was posted to our website on 12/15/2011, and is entitled Preferred location for allergy injections.

In terms of the suggested wait time in the office after allergy injections, I refer you to another extremely helpful document which represent the guidelines for our allergy societies regarding the administration of allergy injections. The reference is available to you online free of charge. It is: 

Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy:  a practice parameter, third update. The Journal of Allergy and Clinical Immunology, September 2011; Volume 127 (1), Supplement, page S1-S55.

I have copied below a link to the site which will pull up all of our practice parameters. The 29th reference is the Practice Parameter on Immunotherapy. You may download and print a PDF by simply clicking on this link.

The above reference, like the website mentioned above, may also serve you regarding future inquiries. 

Finally, should you wish to know further about the variation in practice patterns of allergists regarding the suggestion that patients bring their automatic epinephrine injectors to the site of immunotherapy, the reference is:  Gupta P, et al. Current practice among allergists on writing self-injectable epinephrine prescriptions for immunotherapy patients. The Journal of Allergy and Clinical Immunology 2012 (February), Volume 129(2):571-572.

Thank you again for your inquiry.

Sincerely,
Phil Lieberman, M.D

Previous submission/response to the Ask the Expert website:

Preferred location for allergy shots

Q:
12/15/2011
I was recently told by a new hire that in her previous practice she was advised that when serum is administered in the posterior subcutaneous tissue (arm of course) that patients were more likely to have significant localized reactions. Her technique is to inject more anteriorly which I believe presents the risk of IM deltoid injection on the leaner patient. There is more subcutaneous tissue posteriorly and in my experience this is the appropriate injection site. Can you please provide direction as to what is the best location for serum administration?

A:
We received a very similar inquiry which was posted on our website on October 20, 2011. I believe that the response to that inquiry applies to your question as well, even though the sites you mentioned are slightly different. For your convenience, I have copied the question as well as the response below. I might mention, parenthetically and anecdotally that as a patient who has received allergy injections as well as a physician who has given them I find the best place to be posterior subcutaneous tissue as well. But as you can see from reading the response below we really have no data to confirm either opinion.

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

Posted 10/20/2011
Preferred location for allergy shots
Q:
Will giving allergy shots SQ in the distal part of the upper arm (closer to the elbow) cause bruising and extensive edema versus giving the injection in the medial/back portion of the upper arm? Patients c/o the above issues when our MA gives the allergy shots and the only thing I've observed is that it is given much lower than where I give the shots. Any ideas?

A:
Unfortunately we cannot give you a definitive answer to your question because there are no studies that have compared the locations you mention. I can only express a bias based on personal experience as both a patient who has received allergy injections and as a physician who has administered them.

I have found that injections given in the medial/back portion of the upper arm to be more comfortable and less likely to cause local reactions.

Parenthetically you might find the link below helpful in regards to the technique involved to administer allergy injections.

http://www.fauquierent.net/allergyshotinstruct.htm

http://www.jcaai.org/page/Practice_Parameters/index.v3page;jsessionid=7loei8phmcq9m

AAAAI - American Academy of Allergy Asthma & Immunology