Q:

Question:
12/19/2013
We have a patient with a history of left-sided breast cancer and lymph node dissection who is on allergen immunotherapy and receives all three injections in her right arm. Unfortunately, she has just been diagnosed with new disease in her right breast, and was inquiring about immunotherapy going forward as she will probably need to undergo some surgical treatment on the right side.

I read the question on 3/22/12 which noted the risk of lymphedema and theoretically decreased efficacy from giving IT in an arm that has undergone a lymph node dissection.

Our specific questions are:
1) Is there any contraindication to giving SCIT in another body site? The IT practice parameters specifically refer to the arm, but subcutaneous injections (insulin, heparin) are frequently administered elsewhere, such as the abdomen.

2) Is there any concern with giving immunotherapy in a patient with active malignancy? She is nearly at maintenance dosing, but we wonder if it would best to give the IT a break for now.

Thank you in advance for your time. We look forward to your thoughts.

A:

Thank you for your inquiry.

There is no definitive answer to either one of your questions. All that we can do is cite theoretical considerations about the preferred site of an immunotherapy injection because we have no data comparing sites. In addition, there have been no studies to my knowledge of immunotherapy administered to a patient with an active malignancy.

We have dealt with the issue of alternative sites of injection for immunotherapy previously on our website in a response posted on 02/06/12. For your convenience, I have copied this response below. As you can see from this response, there is clear rationale for the use of the arm, but this does not mean that you could not use an alternate site. We simply do not know how the two sites compare, and in the final analysis, the site you select would be chosen based on clinical judgment. But clearly there is no published admonition against employing use an alternate site.

A similar situation exists for the administration of immunotherapy to patients with active cancer. We have also dealt with this issue previously on our website, and copied below you will see two entries posted to similar questions, one on 03/05/2010 and the other on 09/25/2012. You can access these entries by going to the Ask the Expert website and typing "contraindications to immunotherapy" into the search box.

The conclusion of these responses was that there is no specifically cited contraindication to the administration of immunotherapy in a patient with an active malignancy. The present Parameters on Immunotherapy (1) is moot on this issue. Thus we are left with a conclusion very similar to that reached regarding the site of injection. There is no stated contraindication, and no studies, and therefore the physician caring for the patient is left with a decision purely based upon clinical judgment. Objections to alternative sites and to the administration of immunotherapy in a patient with cancer are all at this time purely theoretical, and there is no empiric evidence to help us deal with these issues. Therefore the clinical decision is reached assessing benefit versus potential risk after a discussion with the patient.

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

Allergy injections in the leg
Question:
02/06/2012
One of our patients wants to start allergy shots but does not want to get the injections in her arms. She states she had a reaction to some type of injection in the past and it took quite a long time to resolve. She asked our provider if she could get the allergy shots in her hips or buttocks. Please advise.

Answer:
We have had this question submitted previously, and I am copying below the previous inquiry and our response to it.

"Best location for immunotherapy injection"
Question:
Can Immunotherapy be given in the thigh?
Answer:
We recently dealt with a similar question, the response to which was posted on 6/28/10. For your convenience, I have copied the question and the response below.

"Location for the administration of allergy injections"
06/28/2010
Question:
Is there any reason why allergy shots cannot be given in the subcutaneous fat of the abdomen or thigh? In my four months of practice, I have had several patients request that the shot be given in these places.

Answer:
There are four reasons for the administration of allergy injections in the arm as follows:

1) If there is anaphylaxis, it has been postulated that a tourniquet tied proximal to the injection site might slow the absorption of antigen.

2) Many physicians wish to follow local reactions, and although there is controversy as to their meaning, it would make it more difficult to view them if the shots were given in the abdomen.

3) Simple convenience.

4) All studies on efficacy have been done using injections in the arm. It is theoretically possible that the difference in antigen processing that might occur with abdominal injections could produce different results.

The first reason noted above is the most important. However, we have no data that the use of a tourniquet is advantageous. Nonetheless, because there are several published articles which cite the potential benefit of a tourniquet, it remains a strategy to be considered should a patient have an anaphylactic reaction.

Of course, the corollary to this is if there is a bad outcome to an injection in the leg or abdomen, the absence of the ability to use a tourniquet might be a consideration in any medical/legal deliberation.

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

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology