Text Box: A BACKGROUND ON RUSH IMMUNOTHERAPY

 

 

 

 

 

SUMMARY: Allergy immunization often fails because people have difficulty maintaining the schedule in the first six months as we edge up the concentrations.   Since the relief is often a function of the dosage, discouragement is common which drastically affects the compliance.

 

I elected to consider RUSH immunization for the following reasons:

 

1. To reduce costs

2.  To improve the safety profile

3. To improve the likely hood of completion of the program     

 

By removing the build-up phase , this procedure removes 25 co-pays  for the patient, and cuts seven months off  the total effort now capped at approximately 1.5 years.  This will reduce the total cost of treatment significantly for both the patient and the carrier.  It also helps us by speeding the profiling of patients since the relief – if it occurs-  will be rapid.   Non-responding patients are discontinued quicker, and responding patients are more likely to complete therapy and enjoy remission for an extended period with few drugs and an improved quality of life.   Office visits drop, antibiotic and antihistamine use is diminished if we can achieve a lasting remission,  and go a long way to making allergy immunization more cost effective.

 

Finally, RUSH may improve the long term safety of allergy injections since the dosage for maintenance is established  on the RUSH visit, making dosage errors very unlikely – particularly when the vaccines are being administered remotely by PCPs.    There are risks for reactions in this intense procedure, but these are anticipated and managed under constant observation.

 

While major allergic reactions are very rare – sore arms from the injection in the first day are VERY common.

 

Text Box: Major abstract: Rush immunotherapy: experience with a one-day schedule. Portnoy J. Ann Allergy Asthma Immunol. 1996 Feb;76(2):175-80. Rush immunotherapy is a method for rapidly desensitizing patients to inhalant allergens. The frequency of systemic reactions during rush immunotherapy is similar to conventional immunotherapy when premedication is used. The most rapid protocol for rush immunotherapy reported to date requires one and one-half days which is inconvenient to patients and clinic schedules. To improve this situation and decrease the cost of giving rush immunotherapy, we have developed a 1-day protocol. METHODS: for this ongoing study, 22 allergic patients received rush immunotherapy consisting of eight injections over six hours followed by two hours of observation in an outpatient clinic. Five had rhinitis and the rest has asthma, seven of whom were steroid-dependent. All were premedicated with astemizole, ranitidine, and prednisone for three days including the day of rush immunotherapy, and peak expiratory low rates were monitored. RESULTS: Systemic reactions were seen in five of 22 (23%). They occurred following the sixth injection (1), seventh injection (2), or the final one (2) and consisted primarily of rhinitis or pulmonary symptoms with one episode of mild anaphylaxis. A systemic reaction was seen in only one steroid-dependent asthmatic patient. A local reaction preceded a systemic reaction in only one patient. All but three reached a maintenance dose in one day. All systemic reactions responded to epinephrine and all patients could go home after rush immunotherapy. Only one patient had a systemic reaction during the three months after rush immunotherapy. CONCLUSION: One day rush immunotherapy is tolerated by most patients with a systemic reaction rate comparable to conventional immunotherapy. All patients were able to reach a maintenance dose months sooner than weekly schedules. With refinement of this procedure, rush immunotherapy may become a widely used method for desensitizing patients with inhalant allergens, and could make immunotherapy less expensive and more convenient.

 

 

 

 

 

 

 

 

Rush immunotherapy (RIT), first described in 1933,  is a technique of advancing an allergic patient to a maintenance dose of an extract in one working day using an injection every 30 minutes over a four hour period with a 1-2 hour observation period at the end. While RIT has been used in the past for time crucial treatments for insect sensitivity, it is now receiving renewed interest because a more rapid effect and reduction of total time and expense of treatment by approximately 40%.  Much of the financial relief occurs in association with less frequent injections in patients with high co-pays.  The major drawback to rapid maintenance and RIT has been an increased level of allergic reactions during the initial phase.  Improvements in safety issues gained by pre-medication on the first day has reduced the risk considerably.  Many physicians and patients believe the benefits involved in the treatments exceed the risks.

Comparason                                                                    TRADITIONAL         RUSH

Time to reduced medication and clinical relief

6-8 months

1-2 weeks

Interval of injections after maintenance

Constant weekly

variable

Total number of injections after maintenance

75

36-48

Length of treatment

24 months

16 months

Reaction rate in first six months:

7-12.5%

10.8% - 38%

Number of co pays to maintenance

24

1

The systemic reaction rate with conventional immunotherapy is 0.1% to 0.51% per injection or 7% to 12.5% per patient over six months  Systemic reaction rates with RIT are approximately 4.6%  - 38% over the first six months depending on the maintenance level chosen.

The profile of patients most likely to consider RUSH immunotherapy include those with:

1. high insurance “co-pays”

2. unpredictable schedules where weekly build up is impossible

3. need for speed of relief

 

People we are reluctant to suggest RUSH include those with:

 

1.       Unstable asthma

2.       Multiple large skin test reactions

 

 

Potential systemic reactions include wheezing, skin rash, flushing, lowered blood pressure.   No death or hospitalization has been reported in recent reviews – but the potential for major reactions exist for traditional and RUSH immunotherapy.

 

PRE-MEDICATION PROTOCOL

 

The following protocol is used in preparation for the procedure:

 

  1. The day before RIT and the morning of RIT:

Prednisone 40 mgm in the morning

Zyrtec 10 mgm in the afternoon

Zantac 150 mgm twice daily

Singulair 10 mgm in the evening

  1. The morning of RIT:

Prednisone 40 mgm

Zyrtec 10 mgm

Zantac 150 mgm

Singulair 10 mgm

 

The RIT Procedure schedule:

8:00 am    Physical Examination, Vital signs, Pulmonary functions, and Heparin lock

consent form signed

 

Injection #                    Time / minutes                 Concentration              Volume

 

1     8:30 am

    0

1:20,000

0.3

2     9: 00 am

  30                               

1:2000

0.1

3    10:00 am

  60

1:2000

0.3

4    10:30 am

  90

1:200

0.05

5    11:00 am

120

1:200

0.1

6    11:50 am

180

1:200

0.2

7    12:30 am

240

1:200

0.3

        1:30 pm

300

Observation

 

        2:00 pm

330

Release

 

 

 

I have read and understand the risks and benefits of RUSH immunotherapy and have had ample opportunity to discuss all aspects of treatment with Dr. Lanier. I have taken the pre-medication in accordance with the protocol

 

 

 

 

X ________________________                                 __________________________

Patients name                                                               Bob Lanier MD