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Allergen Extract Compounding Requirements Updates

March 13, 2020
The USP Appeals Panel has determined the currently official version of <797> (last revised in 2008) remains official as a result of the remand. Recognizing the public health impact of these standards, USP is committed to further stakeholder engagement through forums, roundtables, and other avenues to gather more input on the issues raised in the appeals.

This determination does not alter anticipated, necessary protocol for  allergist/immunologists. The AAAAI will inform its membership of the new implementation date.

For more information, please visit the USP Compounding Appeals webpage.

September 24, 2019
Implementation Date for USP 797 Extended

The United States Pharmacopeia has announced that, due to appeals underway, the previously announced implementation date of December 1, 2019 for Chapter 797 on Pharmaceutical Compounding of Sterile Preparations is officially extended. We do not know at this time what the new implementation deadline will be.
However, there is no reason to believe that any changes will be made to the updated standards for physician in-office compounding of allergen extract. For those of you have initiated changes to meet the updated standards for the compounding area, cleaning, staff training, and documentation, we encourage you to continue those efforts. For those of you who have not started, we strongly encourage you to proceed.
We will keep you updated as soon as more information is available.

June 6, 2019
The new USP Chapter <797> standards were posted on June 1, 2019. These standards become effective December 1, 2019. Read more detailed information prepared by the AAAAI on the updated standards:
USP Chapter 797 Final Requirements
Personnel Qualifications Hygiene

June 3, 2019
Final USP Standards Published

The long-awaited new USP Chapter 797 standards on sterile compounding were released June 1 and take effect Dec. 1.
We are pleased to report that thanks to the vigorous collective advocacy of the allergy community, the final standards mirror the proposed standards released last July. We supported those standards in our comments to USP, and we believe they are reasonable and achievable. A summary of the standards is below, but we encourage you to download the complete version.
Final standards for allergen extract compounding under USP Chapter 797
Under the new standards, to continue in-office compounding of individual treatment sets for allergen immunotherapy, allergy practices will, beginning Dec. 1, need to comply with the following:
1. Personnel Qualifications
•    Designate one person to oversee and evaluate compounding personnel.
•    Provide training and testing on principles and procedures for new staff and annual evaluation for others for sterile compounding, garbing, hygiene, gloved fingertip and thumb sampling and media fill tests.
•    Ensure that compounding personnel wear powder-free sterile gloves; non-cotton, low-lint sleeved garments that gather at the wrist and close at the neck; face mask and disposable cover for head and facial hair.

2. Facilities
•    Compounding must occur in either (1) an ISO Class 5 Primary Engineering Control (PEC) OR (2) in a dedicated Allergenic Extracts Compounding Area (AECA), either of which must not be within one meter from a sink and can't be near unsealed windows, doors to the outside, or high traffic or other areas that present environmental control challenges such as bathrooms or kitchens.
•    If used, a PEC must be certified every 6 months, and cleaned and disinfected before and after each compounding, and surface must be disinfected between each prescription set.
•    An AECA must have a visible perimeter and meet the following conditions:

     o    Access restricted to authorized personnel.
     o    No other activity permitted during compounding.
     o    All surfaces must be cleanable and kept clean.
     o    No carpet is allowed.
     o    No surfaces that can be damaged by cleaning and sanitizing agents.
     o    Surfaces must be smooth, impervious, non-shedding, and free of cracks or crevices.
     o    Overhangs should be avoided or must be easily cleaned.
     o    Well lit, and temperature and humidity controlled for comfort of compounding personnel.
     o    Work surface must be cleaned and disinfected before and after each compounding session, and disinfected between each new set, as well as at the time of any spill or contamination.

•    Vial stoppers on packages of conventionally manufactured sterile ingredients must be disinfected with 70% IPA wipes before each use.
•    Walls, doors, and door frames within and AECA must be disinfected monthly and when contamination is suspected.
•    Ceilings in the AECA must be cleaned and disinfected when visibly soiled.

3. Documentation
•    Labels on prescription sets must include patient name, type and fractional dilution with corresponding vial number, beyond use date, and required storage conditions.
•    Standard Operating Procedures manuals describing required compounding process.
•    Training, assessment results, evaluations, and qualification records for all compounding personnel, including any corrective actions following assessments and evaluations.
•    Certification reports for PEC, if used.
•    Temperature logs for refrigeration.
•    Compounding records for individual extract prescription sets.
•    Information on any complaints and adverse events.
•    Investigations and corrective actions following any complaints and adverse events.

The American Academy of Allergy, Asthma & Immunology, American Academy of Otolaryngic Allergy and American College of Allergy, Asthma & Immunology are pleased that our work with the USP Expert Compounding Committee has resulted in standards that allow for the continued compounding of allergen extract prescription sets for individual patients. We wish to acknowledge Andrew Murphy, MD, FAAAAI, who served as a physician consultant to the USP Expert Compounding Committee, for advocating for continued in-office compounding of allergen extracts to protect patient access to care.
While the lack of any reported cases of an infectious adverse event makes these seem unnecessary, the specialty is willing to acknowledge the USP Expert Compounding Committee's extensive work to create meaningful patient safety standards, and we therefore accept these additional requirements, to reflect our shared dedication to patient safety.
We look forward to ongoing engagement with the USP in policy and standards development and additional issues relevant to ensuring patient safety while protecting access to care and improving patient outcomes.
Stay tuned for information from each organization about upcoming training on how to fully comply with either facility option and other new requirements.

March 5, 2019
AAAAI highlights expected changes to USP

At the 2019 annual meeting in San Francisco, the AAAAI shared information with members on the anticipated changes to USP 797 at the Practice Management Hub. The final update to USP 797 will be released in June, 2019, and an implementation date of December, 2019. See below for handouts on the expected changes.

USP Chapter 797 Proposed Requirements - Personnel Hygiene and Documentation

797 Compounding - Which Will You Choose?

July 27, 2018
Updated Chapter 797 Posted for Public Comment: Separate Requirements for In-office Compounding of Allergen Extract Restored

In September 2015, the United States Pharmacopeia (USP) released a proposed updated Chapter 797 on procedures for sterile compounding. The existing chapter had provided procedures for allergen immunotherapy extracts as a separate element to processes applicable to three levels of risk for other sterile compounded products. The September 2015 draft collapsed those requirements into just two categories; treating all sterile compounds, including allergen extract, as equally and inherently dangerous. The allergy/immunology community immediately responded, sending thousands of comments expressing concern for the continuation of allergen immunotherapy, provided for more than 100 years with no data showing any infectious adverse events. The AAAAI, ACAAI and American Academy of Otolaryngic Allergy have worked collaboratively with the American Medical Association and others to influence the next iteration of the USP Chapter 797 draft.
Today we received the updated draft. Allergen extract is restored as a separate section of the proposed chapter. The allergen extract compounding requirements address compounding personnel training and evaluation, hygiene and garbing, and updated documentation requirements, plus either installation of an ISO Class 5, Primary Engineering Control (PEC), OR a Dedicated Allergenic Extracts Compounding Area (AECA), with specifications and requirements provided for either option.
With the establishment of an AECA, including requirements for the surfaces and surrounding area, a hood is NOT required.
The requirements for an AECA include no carpeting, impervious surfaces, no outside doors or openable windows, a visible perimeter, and additional reasonable expectations for sterile compounding in the physician office. Whether you use a PEC or an AECA, compounding staff will be required to be trained and regularly evaluated on aseptic and compounding technique, mostly reflecting existing requirements but with the addition of fingertip testing and thumb sampling and appropriate incubation of samples to ensure proper sterile technique is being followed. These requirements will help maintain consistent attention to the foremost importance of ensuring patient safety. Documentation requirements for compounding procedures, temperature logs for refrigeration, and prescription set documentation reflect best practices.
The AAAAI, ACAAI, and AAOA thank our many leaders and members who have been actively engaged on this issue, as well as our collaborating organizations, and most importantly the USP Compounding Committee for protecting patient safety while maintaining patient access to allergen immunotherapy through physician in-office compounding of allergenic extracts.
If you wish to view the updated proposed Chapter 797, it is available at Comments on this updated draft are due November 30, 2018. The final version of the Chapter is expected to be posted on June 1, 2019, and to go into effect as of December 1, 2019.  We will be sharing additional details over the next few weeks.

January 2, 2018
Andrew W. Murphy, MD, FAAAAI, Chair of the AAAAI Office of Practice Management and Editor of Practice Matters!, is one of two Physician Expert Consultants newly appointed to advise the United States Pharmacopeia (USP) Compounding Expert Committee as that group continues the process of updating Chapter 797.

The AAAAI has been consistently visible and engaged at USP and Food and Drug Administration (FDA) meetings regarding and impacting in-office compounding, while the American Medical Association (AMA) has pushed for increased physician engagement with the USP. At a September meeting of the USP Expert Committee on Compounding, an AAAAI representative was recognized to answer committee members’ questions regarding immunotherapy procedures that make a longer by-use date necessary for allergen extract than for other in-office compounds. With the AMA accomplishing their effort to encourage physician engagement with USP, the invitation extended to Dr. Murphy reflects the unparalleled engagement of the AAAAI on behalf of the allergy community.

The other physician invited to participate is pulmonologist Dennis E. Doherty, MD, who currently serves as the Chair of the USP Healthcare Quality and Safety Expert Committee.

The USP has indicated that additional physicians may be added as other societies ask to be included.

December 7, 2017
The AAAAI is constantly working to advance the practice of allergen immunotherapy, especially in light of proposed changes to policies and procedures regarding sterile compounding. In response to the Food and Drug Administration’s recent soliciation for information related to providing appropriate regulatory relief, the AAAAI urged the Food and Drug Administration to ensure patients have continued access to allergen immunotherapy (AIT), also known as “allergy shots”.  Review the full letter.

June 9, 2017
Update on USP 797 and FDA Activities Related to Compounding of Patient Specific Allergen Vials for Immunotherapy
Specialty leaders representing physicians from the American Academy of Allergy, Asthma & Immunology, American College of Allergy, Asthma & Immunology, American Academy of Otolaryngic Allergy and the American Academy of Otolaryngology – Head and Neck Surgery, along with the American Medical Association, the American Rhinologic Society and the Allergy and Asthma Network—representing patient concerns—have been actively engaged with the United States Pharmacopeia (USP) and the U.S. Food and Drug Administration (FDA) regarding proposed standards and regulations impacting in-office compounding of allergen extract for immunotherapy.

In follow up to a February 2017 Stakeholder Roundtable on Allergen Immunotherapy, a workgroup has been formed including leadership of the USP Compounding Expert Committee, representatives from the specialty societies and USP staff. This group met on Friday, June 2 for an update on the continuing effort to revise Chapter 797. Discussions included appropriate standards for training of compounding personnel and processes for ensuring sterility in the office setting. The specialty societies reiterated that there is insufficient data to indicate that additional safety equipment or procedures are necessary beyond the current Chapter 797 standards. Representatives of USP stressed the importance of not creating an exception for any group that would appear to require insufficient safety standards compared to those applicable to other compounding settings. All groups agreed to continue working together in pursuit of an approach that will allow for practitioners to continue to provide this life-changing and life-saving evidence-based treatment, while following procedures designed to ensure patient safety.

On Tuesday, June 6 the FDA Center on Drug Evaluation and Research (CDER) Office of Compounding hosted a series of listening sessions with seven different healthcare constituencies regarding compounding practices in different settings. Our specialty societies participated in similar sessions held in June 2016, but it is significant to note that the allergy/immunology and otolaryngology specialties were invited to a separate session from other specialties for the first time this year. This allowed the discussion to focus extensively on concerns related to compounding and administration of allergen immunotherapy. Discussion focused on the 2016 FDA Proposed Guidance on Insanitary Conditions, which the FDA regarded as a follow up to previous regulations and not the precursor to a set of sweeping new requirements on physical facilities. The FDA acknowledged that the implications on a practice such as allergen immunotherapy were not taken into account in its development. Specialty leaders urged an approach that would balance the potential for infectious adverse events, which the FDA admits has not been identified as a problem, with the increased threat of anaphylactic reactions possible if source extract products are not controlled for consistency and patient status in the physician's office.

We will continue to work together and to keep our members apprised as compounding rules and standards are considered and developed.

December 29, 2016
FDA 11th-Hour Guidance on Compounding

As we shared with the Trump transition team and with Congress earlier this month, the AAAAI has been watching for an 11th-hour action from the Food and Drug Administration (FDA) regarding compounding. We have been particularly concerned about any further action on the August 2016 draft guidance entitled “Insanitary Conditions in Compounding Pharmacies” that suggested that state boards of pharmacy should enforce extreme standards on physician offices by, inexplicably, applying them equally to physician offices as to commercial compounding manufacturing facilities.  
The FDA issued a final guidance yesterday afternoon on compounding, focused on prescription requirements. While the final guidance does specifically include physician in-office compounding, it does not appear to reflect the overreaching approach taken in the “Insanitary Conditions” document. Yesterday’s finalized guidance on prescription requirements acknowledges that compounding in the physician’s office reflects a physician/patient relationship. It requires that the patient’s individual prescription needs to be documented, with the patient’s name, in the patient’s medical record. While we recommend that you review the document for yourself, we are pleased to tell you that we find it encouraging.
We are hopeful that this finalized guidance reflects an appreciation for the importance of our ability to provide safe and effective patient care by preparing allergen extract in our offices. Meanwhile, we will certainly continue to remain vigilant for any additional 11th-hour FDA regulations, but we are pleased to share with you what we see as an encouraging step from the FDA.
You can read the final guidance, Prescription Requirement Under Section 503A of the Federal Food, Drug and Cosmetic Act, here:

December 16, 2016
Urgent Compounding Communications

The AAAAI Board of Directors sent a letter November 25 to the Trump Transition team to share our concerns about the FDA’s recent draft guidance, “Insanitary Conditions in Compounding Facilities.” Read the letter.

Although Republican leadership has urged federal agencies to not issue any final regulations in the waning days of 2016, there is no guarantee the FDA will not issue a final guidance. On December 2 we shared our letter with members of Congress, along with a reminder of the letter sent by Senator Casey and colleagues to the Department of Health and Human Services, expressing concern about the draft guidance.

November 23, 2016
Transition Team Letter

November 2016
AAAAI Keeps Compounding Concerns Before the AMA House of Delegates
The AAAAI submitted a resolution to the recent American Medical Association (AMA) House of Delegates Interim Meeting calling attention to the Food and Drug Administration’s (FDA) recent draft guidance, “Insanitary Conditions in Compounding Facilities.” This draft guidance inexplicably included physician in-office compounding in its definition of compounding facilities, which was inconsistent with any previous FDA action. The resolution called for the FDA to withdraw the draft guidance until the United States Pharmacopeia (USP) completes its revision of USP Chapter 797, which provides standards for sterile compounding.
The AAAAI worked with a number of other specialties to build support for the effort, and significant discussion and testimony were shared in Reference Committee. Ultimately, a final resolution was approved that called for FDA to remove physician in-office compounding, and also ambulatory surgery centers, from their definition of compounding facilities, without specific reference to the draft guidance regarding insanitary conditions. We are very pleased with this outcome and send our deepest thanks to the AAAAI’s AMA voting delegate, Steven G. Tolber, MD, FAAAAI, and alternate delegate and previous longtime delegate, George R. Green, MD, FAAAAI.
We also recognize and thank the American College of Allergy, Asthma & Immunology delegate Alnoor A. Malick, MD, FAAAAI, American Academy of Otolaryngic Allergy delegate Wesley D. Vander Ark, MD, and also Kira A. Geraci-Ciardullo, MD, and Stephen A. Imbeau, MD. Finally, we celebrate the outstanding leadership of AMA House of Delegates Chair, Susan R. Bailey, MD, FAAAAI.

October 2016
The AAAAI continually works to protect and advance patient access to evidence-based care, including allergen immunotherapy. This practice requires a very personalized approach, as each patient’s allergen extracts are mixed individually, and vials of extract may be modified over the course of treatment to adapt for treatment progress, ongoing symptoms, or changes in the patient’s treatment schedule or overall condition. This makes it necessary that allergists and their staff be able to manage these extracts in the physician’s office, both at the start of treatment and sometimes later in the course of treatment.
In September 2015, the United States Pharmacopeia proposed revisions to its General Chapter 797, which outlines standards for pharmaceutical sterile compounding. The current Chapter 797 sets forth varying requirements for sterile compounding based on risk, with a special exception for allergen extracts. The 2015 proposed revision treats all compounding as equally and inherently dangerous, thereby requiring the same procedures for allergen extract compounding as all other compounded materials, despite the significant difference in potential risk between the administration of allergy shots and other kinds of injections. The response to the proposed revisions has been enormous, and consideration of the comments and their implications have pushed the USP’s timeline for updating Chapter 797 beyond 2017.
In August 2016, the FDA issued a draft guidance titled “Insanitary Conditions at Compounding Facilities,” and specifically includes physicians’ offices. The draft guidance describes a set of conditions for which any compounding should be considered insanitary, and those conditions include any environment that does not utilize the kinds of extraordinary and expensive safety protocols previously only required for higher level risk procedures under the existing Chapter 797.
Although an FDA draft guidance is non-binding and does not carry the weight of law, the draft guidance encourages state regulatory agencies to actively enforce these recommendations under their own state laws, thus superseding existing FDA regulation that requires those engaged in compounding activities to follow current requirements set forth under USP Chapter 797.
The AAAAI and others are actively seeking a reversal of the draft guidance.

Insanitary Conditions at Compounding Facilities - September 2016
FDA Comments, Townhall - June 3, 2016
Mixing, Diluting, or Repackaging Biological Products Outside the Scope of an Approved Biologics License Application - May 2015

September 2016
Update on Proposed Changes to USP Chapter 797
The United States Pharmacopeia (USP) Compounding Expert Committee is meeting next week, with 90 minutes on the agenda set aside for all issues relevant to Chapter 797. The AAAAI, American College of Allergy, Asthma & Immunology and the American Academy of Otolaryngic Allergy will all be attending. It is expected there will be very little time spent on allergy/immunology concerns, although it is anticipated that USP will acknowledge the deluge of feedback received from the allergy/immunology community. We also anticipate the announcement of a stakeholder meeting to be held later in the fall that will focus on allergy/immunology concerns. The AAAAI will continue to keep you informed and work collaboratively with our members and other organizations to influence this very important issue for our specialty.

August 2016
AAAAI and Others to Attend USP Compounding Expert Committee Meeting

The United States Pharmacopeia (USP) Compounding Expert Committee will meet September 20, and the AAAAI, the American College of Allergy, Asthma & Immunology and the American Academy of Otolaryngic Allergy are all planning to participate. Chapter 797 has 45 minutes on the agenda, during which the timeline, public comments, and stakeholder meetings to follow up on those comments will be discussed. Because the issues resulting from the 797 proposal impact a wide variety of specialties and concerns, we anticipate that allergy will be a fairly small part of this discussion, even though we have heard that we generated the majority of the comments.

We are currently awaiting details on a stakeholder meeting focused on allergy concerns later in the fall. The AAAAI continues to make working on behalf of the specialty in regards to access to allergen immunotherapy, and collaborating with others to do so, a top priority. We will keep you informed through Practice Matters, eNews and additional email updates.

July 21, 2016
Immunotherapy Safety and United States Pharmacopeia (USP) 797 Update

The AAAAI remains committed to advancing the practice of allergen immunotherapy and continues to fight the Chapter 797 changes proposed by the United States Pharmacopeia (USP). As communicated in June Practice Matters, AAAAI and other organizations participated in a June 3 Food and Drug Administration (FDA) listening session on compounding. Advocacy Chair Andrew W. Murphy, MD, FAAAAI, spoke with USP representatives in person at that meeting to reinforce our concerns. Executive Vice President Thomas B. Casale, MD, FAAAAI, Past President Linda Cox, MD, FAAAAI, Board member Aidan A. Long, MD, FAAAAI, and others also spoke with leaders from USP at the Eastern Allergy conference in Palm Beach, Florida on June 4.

The AAAAI recently submitted comments to the FDA in response to proposed rules about compounding in hospital and health system pharmacies. One proposed rule would allow products compounded by such a pharmacy to only be administered within one mile of the facility. We told FDA this threatens access to allergen immunotherapy for patients seen by staff physicians of healthcare systems who practice in community clinics, some of which are in economically depressed areas where pediatric patients receive allergen immunotherapy for allergic asthma. We reiterated that any proposed change to compounding rules must balance perceived safety risks with patient access to proven, safe and effective medical care. See the AAAAI's comments.

The AAAAI received support from the American College of Physicians (ACP), which also submitted comments to the FDA in support of patient access to care and safety concerns that necessitate allergen extracts prepared via physician in-office compounding. See the ACP's letter.

Additional postings from the FDA earlier this week will also be commented on, and outreach to members of Congress and other interested organizations continues as well. While it is difficult to estimate when the USP issue will be resolved, we are extremely confident that USP is much more aware and tuned into the concerns of the A/I community related to the proposed Chapter 797 changes.

June 16, 2016
Immunotherapy Safety and United States Pharmacopeia (USP) 797 Update: Comments Presented to FDA and Casey Letter Delivered to HHS
The AAAAI has been constantly working to advance the practice of allergen immunotherapy, especially in light of proposed changes to policies and procedures regarding sterile compounding. Several notable updates include the AAAAI's attendance at a Food and Drug Administration (FDA) listening session on compounding and the delivery of Senator Bob Casey's letter to Department of Health & Human Services (HHS) Secretary Burwell.

AAAAI Presents Comments at FDA Listening Session on Compounding
Advocacy Chair Andrew Murphy, MD, FAAAAI, attended a June 3 FDA listening session on compounding and presented comments on behalf of the AAAAI. Read the comments.

The AAAAI was informed of the listening session by colleagues at the American College of Physicians, who the AAAAI has been working with on the compounding issue. After securing an invitation, the AAAAI requested that the American College of Allergy, Asthma and Immunology (ACAAI) and American Academy of Otolaryngic Allergy (AAOA) receive invitations as well. All three groups collaborated and coordinated to ensure a consistent message was being delivered while preserving the unique perspective of each organization. While this was strictly a listening session, the AAAAI had the opportunity to continue strategic discussions with the American Medical Association (AMA), Federation of State Medical Boards (FSMB) and USP after the meeting.

Casey Letter Delivered to HHS Secretary Burwell
At the request of the AAAAI, Senator Bob Casey (D-PA) has sent a letter to HHS Secretary Burwell expressing concern about the USP proposal and the extent to which it could "…significantly reduce access to allergen immunotherapy and increase costs, without any evidence that it would prevent infections that, to date, have not been documented in any patients." A total of 13 Senators signed the letter, and these six Democrats and seven Republicans include some very respected and high-ranking Senators. Read the final version of the letter.

While circulating the letter, we received the attention of a number of Senators who did not sign on but indicated they planned to schedule calls with the FDA or contacts in Secretary Burwell's office to express their concern. The AAAAI's representation in Washington, DC will circle back to these offices.

Thank you to every AAAAI member who took action by calling their Senators and urging them to sign on to the Casey letter. The AAAAI will continue to keep you updated on our efforts to maintain the current USP standards for compounding allergen immunotherapy extracts.

April 29, 2016
The AAAAI is constantly working to advance the practice of allergen immunotherapy, especially in light of proposed changes to policies and procedures regarding sterile compounding.

FSMB Position Statement Will Not Advance; Further Study Likely to Follow
Jennifer Namazy, MD, FAAAAI, presented testimony on behalf of the AAAAI before the Reference Committee of the Federation of State Medical Boards (FSMB) this morning in San Diego, against a proposed position statement that called for an end to in-office physician sterile compounding. She described and distributed the recent Massachusetts General Hospital/Brigham and Women's Hospital study (in press in JACI) showing no infectious events associated with over 130,000 allergy injections provided by two allergy practices to more than 3,000 patients over 10 years. She also provided a compelling description of her patient, a young man who lives on a ranch in California, for whom immunotherapy for a hymenoptera allergy has been a life-changing therapy.

Dr. Namazy's comments were well received and referenced by others who also gave testimony as to the importance of further study so that restrictions on physician compounding would not result in limiting patient access to guideline-based medical treatment. Read Dr. Namazy's comments.

Dr. Arthur Hengerer, the Chair-elect of the FSMB, informed the Reference Committee that the FSMB Board of Directors had discussed the issue and, after receiving and reviewing input from numerous state medical boards and input sent directly to the FSMB from many in the allergy/immunology community and a variety of other specialties, recommended withdrawing the draft position statement. The FSMB Board recommended that a study of the issue, as proposed in a resolution offered by the North Carolina Medical Board, should be undertaken to identify more appropriate policy for the FSMB regarding physician compounding. The issue will be heard again tomorrow by the FSMB House of Delegates.

The AAAAI thanks Dr. Namazy and everyone who contacted their state medical boards, and will continue to keep you informed as this process continues. Advocacy on behalf of our patients requires that all A/I physicians stand up and voice their opinions. One person alone cannot solve the myriad of challenges that we face. We believe that a stake-holder engaged, transparent process of discussing ramifications on restrictions on physician compounding for evidence-based care will not only result in a more appropriate position for the FSMB, but may also advance our ongoing advocacy with USP to maintain the current USP standards for compounding allergen immunotherapy extracts.

What's Next? Tell Your Senator to Co-Sign Casey Letter to HHS
At the request of the AAAAI, Senator Bob Casey (D-Pa) is sending a letter to U.S. Department of Health & Human Services (HHS) Secretary Burwell expressing concern about the USP proposal and the extent to which it could "…significantly reduce access to allergen immunotherapy and increase costs, without any evidence that it would prevent infections that, to date, have not been documented in any patients." Senator Casey has asked other Senators to co-sign with him. Read Senator Casey's letter and request to other Senators.

A less effective—but easy—option is to submit your comments via the email/comment link on your Senator's website. Thank you in advance for helping the AAAAI with this next opportunity for engagement.

April 13, 2016
Immunotherapy Safety and United States Pharmacopeia (USP) 797 Update: A New Study, A Survey & Your State Board
The AAAAI is constantly working to advance the practice of allergen immunotherapy. Important updates you need to know include a new study released this week supporting the safety of immunotherapy administration; an invitation to participate in the updated adverse events survey; and an update on communications with state medical boards regarding in-office compounding.
New Study on Immunotherapy Safety
In an article published by The Journal of Allergy and Clinical Immunology (JACI), researchers from Massachusetts General Hospital have confirmed the safety of current allergen immunotherapy (AIT or allergy shots) practices. In more than 130,000 injections given to over 3,000 patients in a 10 year timeframe, no infectious events related to the allergy injections occurred. We are also sharing this new data with USP in follow up to our previous request that current standards for sterile compounding for allergen immunotherapy remain in effect. Read the article here.
Immunotherapy Adverse Events Survey Now Open  
The AAAAI has collaboratively supported the Annual Anaphylaxis Survey for 7 years, and worked with David Bernstein, MD, FAAAAI, and others to update this year's survey to include both SCIT and SLIT. In addition, information will be gathered on infection risk from SCIT injections in response to concerns raised by USP. To participate, contact for a special code and a link to the survey.
Federation of State Medical Boards Position Statement on In-Office Compounding
The Federation of State Medical Boards (FSMB) discussed a position statement at their meeting in San Diego at the end of April that discouraged any sterile compounding in physicians' offices. The AAAAI initiated a multi-specialty effort to defeat this position statement, and signed on to a collaborative letter to all state medical boards. The American Medical Association (AMA) then shared information on this effort with all specialty societies seated in the House of Delegates, suggesting their state level organizations contact their state medical boards if impacted by this position statement.

Ongoing Opportunities
Remember that you can invite your patients to weigh in on the importance of access to allergen immunotherapy from their perspective. Share the petition in your office, today and every day.

If you missed the AAAAI's panel discussion on USP 797 at the 2016 Annual Meeting, watch it here. It covers USP's proposed changes to the sterile compounding rules, its potential implications on the allergy/immunology specialty and what the AAAAI has done about the issue.

The AAAAI will continue to provide updates in Practice Matters and eNews; and our thanks for the many calls and emails we continue to receive on these important issues.

March 30, 2016
Watch the USP Panel Video from the 2016 AAAAI Annual Meeting.

February 1, 2016
What You Need to Know about Proposed Changes to USP 797

As previously reported to AAAAI members, the practice of allergen immunotherapy as we know it is at risk. The United States Pharmacopeia (USP) has proposed changes to be required of all sterile compounding, including allergen extract preparation.

These changes include more complicated mixing procedures, significantly shortened timeframes for how long extracts can be used, and add burden to your storage and documentation processes. Thank you to everyone who submitted comments to USP during this public comment period and to all who shared the AAAAI’s petition to save patient access to allergen immunotherapy. The response from AAAAI members and their patients was extraordinary.

In addition, the AAAAI collaborated with the American College of Allergy, Asthma & Immunology and its Advocacy Council; the American Rhinologic Society; the American Association of Otolaryngic Allergy; the American Academy of Otolaryngology-Head and Neck Surgery; and the Allergy and Asthma Network to develop comments to send to USP.

You can read our letter.

The AAAAI will continue to keep you updated on the situation as we learn more.

January 27, 2016
USP Update Could Significantly Change In-House Compounding and Patient Access to Immunotherapy

AAAAI Members Urged to Submit Comments to USP by January 31, 2016
As reported in the December issue of Practice Matters and a special Practice Matters alert emailed to AAAAI members yesterday, the practice of allergen immunotherapy as we know it is at risk. The United States Pharmacopeia (USP) has proposed changes to be required of all sterile compounding, including allergen extract preparation. These changes include more complicated mixing procedures, significantly shortened timeframes for how long extracts can be used, and add burden to your storage and documentation processes. These changes are included in a draft update of the USP Chapter 797, which governs sterile compounding, and which is available for public comment until January 31.

This is a critical issue that the AAAAI and ACAAI have been working together to address. If you have not already submitted comments to USP, you are urged to do so by the January 31 deadline. Keep these details in mind:

•    The AAAAI's representation in Washington, DC, and a jointly retained consultant have informed us that having members submit personalized comments will be most effective in getting our voice heard. The AAAAI has compiled a variety of information, which you can use to help put together your personalized comments to USP. The most important information is in all capital letters.

•    Members should absolutely communicate with their patients about these proposed USP changes. If the changes are finalized, it will significantly impact patient access to immunotherapy. If you have patients who will personally attest to an improved quality of life thanks to allergen immunotherapy, please invite them to participate in this public comment period as well.

Go directly to the USP site to read the draft update of USP Chapter 797 and download the comment submission template you must use. If you have any questions, contact the AAAAI at

The AAAAI will continue to update you on this situation.