Q:

1/3/2013
1. Given the Practice Guidelines indicate the use of Beta Blockers are a relative contraindication in the administration of allergen immunotherapy, is there any data that would suggest there is less of a risk if the patient on a Beta Blocker holds the Beta Blocker for 24-48 hours prior to the receipt of the allergy injection? Would administering allergy shots under these circumstances be defendable were there a severe reaction to the allergy shot?

2. Given the Practice Guidelines for patients on Venom Immunotherapy indicate the use of Ace Inhibitors is contraindicated, similarly is there any evidence that holding the Ace Inhibitor for 24-48 hours prior to the receipt of the Venom allergy injection might pose less of a risk? Would administering the venom allergy shot under these circumstances be defendable were a severe reaction occur? Thank you in advance.

A:

Thank you for your inquiry.

The question that you ask is certainly a cogent one, and through the years, this topic has been “bantered about”, and the question has been asked of me personally in the past. Unfortunately, the key word in your inquiry is “data.”

There are no data available in the literature to my knowledge, nor could I find any via a literature search, that has been gathered to address this issue. Therefore, I cannot give you an evidence-based response.

Intuitively, one would suspect that such a strategy would clearly lessen the impact of the drug on predisposing the patient to an episode or enhancing its severity. But there is no information in the literature to confirm this intuitive impression. Thus, I am afraid there is no definitive answer to your question, and the decision to employ such a strategy during immunotherapy would simply be left up to the physician administering the therapy after an analysis of the risk/benefit ratio.

I will say, however, when immunotherapy has been necessary (for example, in a patient who has had a near fatal reaction to a sting), and a beta-blocker or an ACE inhibitor cannot be discontinued, I have personally used this strategy to proceed with treatment. Nonetheless, I could not state whether this would be a defendable act, not only because there is, as noted, no data in the literature to confirm its efficacy, but also because the term “defendable” itself is subject to a wide range of interpretation depending upon the circumstances involved.

Thank you again for your inquiry and I am sorry that I could not give you a specific answer to what is a problem that we all face frequently in practice.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology