Thank you for your inquiry.
There are a number of ways one could interpret the phrase "problem with immunotherapy." The first of course is whether or not immunotherapy is contraindicated in this patient.
In my opinion, there is no specific or definitive contraindication to the administration of immunotherapy in your patient, but some would argue that the presence of any autoimmune disease (in this case, specifically rheumatoid arthritis) would be a relative contraindication. However, I don't share this opinion. Nonetheless, there are problems with the initiation of immunotherapy in this patient in regards to whether or not it would be of help, and because of these, I personally would be reluctant to administer immunotherapy in this situation. The reasons for this are:
1. It is highly unlikely, because of his age, even if he does demonstrate sensitivity to aeroallergens via skin or serum testing, that the major component of his rhinitis is allergic. At his age, he could have a strong, and quite possibly a dominant nonallergic component. In this case, immunotherapy would not be effective.
2. In addition, he is taking two drugs that suppress immune response and therefore could diminish the response to immunotherapy.
3. Finally, as noted, there are those who might say that the presence of rheumatoid arthritis would alone be a relative contraindication.
Thus, based upon the overall view, I would be reluctant to initiate immunotherapy in this patient.
Thank you again for your inquiry and we hope this response is helpful to you.
Phil Lieberman, M.D.