Dose adjustment practices among allergists for local reactions to immunotherapy

Background: Dose adjustments for local reactions to immunotherapy have been previously proposed. Several studies have shown that systemic reactions from immunotherapy injections are not predicted by previous local reactions. However, no previous reports have evaluated the prevalence and rationale of dose adjustment protocols within allergists' practices. Objective: To examine allergists' response after patients' local reaction to immunotherapy. Methods: On behalf of the American College of Allergy, Asthma and Immunology (ACAAI) Immunotherapy and Diagnostics Committee, an electronic survey was sent to all practicing allergists of the ACAAI. Participants were asked whether they make dose adjustments for local reactions to immunotherapy and the rationale behind this decision. Strategies to prevent and minimize local reactions were also queried. Results: A total of 2,797 electronic letters were successfully sent, and 761 allergists (27.2%) responded to the survey, with 94.7% of the participants having completed a fellowship in allergy and immunology. Common strategies used by allergists to prevent and minimize local reactions included a dose adjustment based on the local reaction from the previous injection (79.1 %) and pretreatment with an antihistamine (70.1%). Most allergists (91.9%) dose adjusted for local reactions. Most of these dose adjustments were based on protocols that included criteria for both repeating and decreasing the dose of immunotherapy based on the size of the local reaction. Rationales used by allergists for local reaction dose adjustment protocols included beliefs that local reactions cause discomfort that leads to patient noncompliance (88.9%), local reactions are predictive of future local reactions (45.7%), and local reactions are predictive of future systemic reactions (29.2%). Conclusions: Our survey results indicate that most allergists dose adjust for local reactions to allergen immunotherapy. Although most allergists agree that local reactions are not predictive of future systemic reactions, the 2 main reasons for dose adjustments include the concern that local reactions cause discomfort that may lead to patient noncompliance with immunotherapy and the concern that local reactions are predictive of future local reactions.