Immunotherapy

Question 1

SLIT contraindications

Answer 1

1. uncontrolled asthma
2. hx hypersensitivity to the ingredients in SLIT
3. hx of severe local rxn to SLIT
4. hx of EoE
5. hx of reaction on any SLIT products
6. active mouth ulcers, lichen planus or dental extractions

Question 2

Indications for allergen specific IT (AIT)

Answer 2

1. pts with stinging insect allergy
2. pts with allergic rhinitis or allergic asthma who have evidence of sIgE to clinically relevant allergies, this includes patients who:
   - do not achieve control of sx with avoidance measures and pharma
   - do not want ongoing to long term meds
   - experience undesirable SE with meds
   - pats with AD and associated aeroallergen sensitization (may be considered)
3. can consider VIT in patients who get disabling large local reactions (B)
4. can help AD in patients with aeroallergen sensitization (B)

Question 3

CI to AIT

Answer 3

1. pts with severe or uncontrolled asthma
2. significant co morbid disease such as CVD
3. patients on BB (absolute CI to AIT, relative with VIT)

Question 4

special considerations in AIT

Answer 4

1. Children < 6 years
2. Pregnancy
3. Elderly
4. pts with malignancy, ID or AI disease

Question 5

Oralair contain which grasses?

Answer 5

timothy 
cocksfoot
rye grass
meadow grass 
sweet vernal grass

Question 6

age for oralair

Answer 6

age 5-50

start 16 weeks before season

Question 7

grasstex age indication, initiation timing, dose

Answer 7

> 5 years old and 8 weeks before season

dose is 2800 BAU

Question 8

ragwitek age indication, initiation, dose

Answer 8

5 y.o
12 weeks before the season
12 Amb a 1 U

Question 9

acarizax age indication, initiation and dose

Answer 9

18-65 years, any time of year, 1 sublingual tablet daily

Question 10

Tree pollen season in

1. BC
2. Prairie
3. ON and QC
4. Maritimes and NFL/L

Answer 10

1. early feb to mid july (costal, deciduous)
   late march to mid july (interior, deciduous)
2. first week april to june
3. april
4. late march to june

Question 11

name some deciduous trees

Answer 11

alder, birch, oak, elm, willow, poplar

Question 12

Grass pollen season in

1. BC
2. Prairies
3. ON and QC
4. Maritime and NFL?L

Answer 12

1. end of april to september
2. may to september
3. late may to june
4. mid may to sept

Question 13

Mould spores by province:

1. BC
2. Prairies
3. ON and QC
4. Maritimes

Answer 13

1. present throughout the year, except for a few weeks when ground is frozen
2. Spring , summer and early fall
3. spring, summer and early fall
4. late summer and early fall

Question 14

Weed pollen by province

Answer 14

1. BC - minimal ragweed
2. mostly nettles and sage, some ragweed in Manitoba
3. ON - Aug to first frost
4. Maritimes - Aug to first frost

Question 15

How to make IT safe in your office

Answer 15

1. enquire about current medical conditions
2. peak flow check if history of asthma
3. waiting time of 30 mins after shot
4. ensure pt is informed of S/S
5. switch pts off BB and ACEi

Question 16

Name some RFs which place pts on AIT at risk for anaphylaxis

Answer 16

1. severe uncontrolled asthma
2. asthma sx present immediately before getting AIT
3. history of sx reactions to AIT
4. dosage errors
5. first injection from a vial
6. use of BB or ACEi
7. home AIT or unsupervised clinic setting

Question 17

Advantages and disadvantages of SLIT

Answer 17

Advan:

1. home administration
2. fewer systemic reactions
3. less complex dosing regimen

disadvan:

1. relies on patient administration
2. possibly less efficacious than AIT
3. requires daily admin vs weekly

Question 18

what antigen is used in honey bee vaccine?

Answer 18

phosphlipase A2

Question 19

what antigen is used in yellow jacket vaccine?

Answer 19

hyaluronidase ves v2 or antigen 5

Question 20

name some errors that can leads to a systemic reaction when on IT

Answer 20

• dosing error
• wrong patient
• IV injection
• new maintenance with new vial
• BB
• pt has uncontrolled asthma

Question 21

long term mgmt of venom allergy

Answer 21

1. wear long sleeved clothing when outdoors
2. avoid walking outside barefoot
3. avoid brightly coloured clothing
4. carry EpiPen
5. obtain medical alert bracelet
6. avoid food outdoors, especially open cans

Question 22

efficacy of IT in asthma

Answer 22

1. improved sx scores
2. decreased medication use
3. decreased exacerbations
4. reduced bronchial hyper responsiveness
5. improved pulm. function
6. may prevent onset of asthma in atopic individuals

Question 23

Benefits of IT in asthma (studies)

Answer 23

1. modification of the natural history of disease
2. reduction in the need for chronic meds
3. treatment of both lower and upper airway disease

Question 24

evidence for SCIT and AD

Answer 24

AD may respond to SCIT if the pt is sensitized to inhalant allergens - based on systematic review and a meta analysis of 8 studies with 385 subjects-

Question 25

what are the AIT preparations?

Answer 25

1. aqueous 2. glycerinated 3. lyophilized

Question 26

dust mite SCIT and SLIT dosing

Answer 26

1. SCIT: D. Farinea 1000 AU/ml and D. pteronyssinus 100 AU/ml 2. Acarizax 12 SQ-HDM SL tb OD

Question 27

Indications for Benralizumab and dosing

Answer 27

- severe asthma with eosinophilic phenotype - > 12 years old - eos > 300 - 30 mg SQ Q 4 weeks for 3 months then every 8 weeks

Question 28

Indications for Reslizumab and dosing

Answer 28

- > 18 years old - Eos > 400 - 3 mg/kg Q 4 weeks

Question 29

Dupilumab dose and eos indication

Answer 29

- no lower eos limit, 150 and 300 accepted | - max dose 600 mg, usually 300 mg Q weekly

Question 30

Indications and dosing for Mepolizumab

Answer 30

- add on maintenance treatment for with severe asthma , > 6 years old and older with an eosinophilic phenotype - EGPA - tx for age 12 + with HES > 6 months with no identifiable cause - eos > 150 - dosing: 100 mg Q4 weeks - EGPA and HES - 300 mg Q 4 wks (100 mg syringes)

Question 31

Xolair indications

Answer 31

1. refractory asthma on step 4 and 5 of GINA 2. > 6 years old with sens. to inhaled aeroallergen on SPT or sIgE AND a total serum IgE and body weight within the dosing ranges AND more than a specific number of asthma exacerbations per year IgE 30 -700 adults IgE 30-1300 kids weight 20- 150 kg

Question 32

factors to ensure scientific validity in a trial

Answer 32

1. randomization 2. control groups 3. blinded study 4. clearly defined exposures 5. use of objective data sources

Question 33

Grasstek ingredients

Answer 33

gelatin, mannitol and sodium hydroxide

Question 34

oralair ingredients

Answer 34

mannitol, cellulose, lactose and silica

Question 35

ragwitek ingredients

Answer 35

gelatin (fish), mannitol, sodium hydroxide

Question 36

acarizax ingredients

Answer 36

gelatin, mannitol, sodium hydroxide

Question 37

itulatex ingredients

Answer 37

gelatin (fish), mannitol and sodium hydroxide