Indications for immunotherapy

1. A history indicating that exposure to a particular allergen precipitates symptoms and contributes to illness.
2. Documented sensitisation to the clinically relevant aeroallergen (by skinprick or radioallergosorbic tests).
3. Future exposure to the allergen should be unavoidable or only partially reducible.
4. Asthma symptoms should be stable. However, the severity of asthma should not be an indication or contraindication for therapy, but would determine whether the injections should be given in a hospital (see contraindications and practical aspects).
5. Significant allergic upper airway or ocular disease strengthens the indication. Clinical experience suggests that adequate control of allergic rhinitis improves the management of asthma. The efficacy of immunotherapy in controlling the symptoms of allergic rhinitis has been established, but is not the subject of this report.
6. An effective allergen extract should be available. Efficacy has been established for grass pollen, ragweed pollen (North America), house dust mite, birch pollen and cat dander. There are uncontrolled studies on other aeroallergen extracts and the decision to attempt a therapeutic trial with a commercially available extract rests with the supervising consultant.
7. Patients or parents/guardians should be able to give informed consent.
8. Other, less tangible, factors, such as unwillingness of the patient to continue with indefinite drug therapy and the quality of life desired by the patient, as well as socioeconomic factors should be considered in the selection of patients for immunotherapy.

Contraindications for immunotherapy

1. If the FEV1 (forced expiratory volume in one second) is less than 70% of predicted, then immunotherapy should not be initiated unless a consultant physician with training and expertise in the management of asthma and immunotherapy has established that the potential benefits outweigh any risks, and the administration environment is suitable (see practical aspects).
2. Unstable asthma, defined by nocturnal asthma, use of a bronchodilator more than three times a week (excluding exercise), peak flow variability of more than 20%, or a bronchodilator response greater than 20%, are relative contraindications to both initiating and continuing immunotherapy. Patients with unstable asthma should not be given immunotherapy outside of hospital.
3. Immunotherapy should not be initiated in patients with autoimmune disease or malignancy,³ although there are data which indicate that it does not predispose to development of these conditions.³¹
4. Immunotherapy during pregnancy has not been associated with an increased risk of teratogenesis. Nevertheless, we recommend that immunotherapy not be given because of the risk to the fetus of a systemic allergic reaction.
5. Should bronchospasm to an immunotherapy dose occur, the therapy should be suspended pending careful assessment by the consultant to determine whether the risk of continuing with the treatment is justified.
6. Patients with eczema may notice a flare of their skin disease during immunotherapy and should be appropriately informed. A significant reduction in dosage may be required to allow the eczema to subside.
7. While immunotherapy for asthma appears to be more beneficial in children than adults, particularly in children with seasonal hay fever and mild coexistent asthma, clinicians should consider carefully whether immunotherapy is appropriate in children when asthma is the only indication.
8. Beta-Blocker eye drops (asthma is a relative contraindication to the use of these).

1. Concomitant administration of beta-blockers and immunotherapy is absolutely contraindicated because patients taking beta-blockers are at increased risk of anaphylaxis and respond poorly to resuscitation (note that the use of beta-blockers is contraindicated in bronchial asthma).
2. Clinicians with no training or experience in giving immunotherapy should not attempt this form of treatment.
3. Lack of adequate resuscitation facilities and equipment.
4. Previous anaphylactic reaction to immunotherapy.

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