Immunotherapies

Question 1

What are the main categories/types of immunotherapies?

Answer 1

Immunoglobulin G, hypoerimmune globulins, IgG anti-D antibody, Allergen desensitization, Anti-IgE therapy

Question 2

What can you treat with IV IgG and how long can the effect last?

Answer 2

Primary and secondary immune deficiency states, autoimmune disorders and inflammatory disorders. The effects can last 2-3 weeks.

Question 3

What can you find in IV IgG in small amounts and why is this important?

Answer 3

IgA, patients with IgA deficiences can have a auto-imune response (anaphylactic response)

Question 4

What is the most common path of administration and the side effects of IgG? How can you reduce the SE?

Answer 4

IV, fever, chills, malaise, HA, dyspnea, urticaria, anaphylaxis (IgA def), thrombosis, hemolysis, kidney injury. Pre-treatment-hydrate, otc nsaid, histamine blocker(H!) like benedryl and possibly sterioids. Test for blood borne pathogens and relevant viral infections as well as renal/liver function.

Question 5

What is hyperimmune globulin and what are some common conditions it is used to treat?

Answer 5

Prepared from the plasma of donors with high titers of antibody against a specific organism or antigen (hep b, rabies, tetanus, varicella-zoster) Provides instant but short lived immunity.

Question 6

What are some special considerations of using immune globulins?

Answer 6

may decrease efficacy of live vaccines (should hold for 6 months), a vaccine immediately prior may need to be repeated, don’t give to patients with IgA antibodies.

Question 7

What is HBIG and what are it’s uses/SE/CI?

Answer 7

Side effects: allergic reaction, back pain, general feeling of discomfort, headache, muscle pain, nausea, pain or bleeding at the injection site

Contraindications: allergy to human immune globulin

Give within 14 days of exposure

Give with Hepatitis B vaccination for long lasting immunity

Question 8

How can you treat a rabies exposure?

Answer 8

Rabies immune globulin injected around wound and the rest IM in gluteal region. Administer vaccine at the same time.

Question 9

What is TIG and what are it’s indications/SE/CI?

Answer 9

Indications:
uncertain of their history of tetanus vaccination or if they have not completed their tetanus series
AND has a wound that is unclean or is significant

Administration: IM and with vaccine

Side effects: anaphylaxis, angioedema, pain or tenderness at the injection site, nephritic syndrome

Contraindications: allergy to tetanus toxoid, or if IM injection is contraindicated due to bleeding concerns

Question 10

Who would you treat with VariZIG?

Answer 10

post exposure prophylaxis for immunocompromised individuals without history of immunity; newborns of mothers with varicella or zoster within 5 days before or 48 hours after delivery

Question 11

What are some SE of VariZIG and other barriers to use?

Answer 11

Side effects: anaphylaxis, pain at injection site, chills, fatigue, rash, nausea, thrombosis
Limited quantities available, expensive

Question 12

What is Rh disease and what mother/combinations cause it?

Answer 12

Rh is Rhesus disease and happens when a mother who is Rh- has a child with a Rh+ man and develops antibodies to Rh+. Complications arise during subsequent pregnancies.

Question 13

How can you treat Rh disease if it’s suspected?

Answer 13

You can use Rho(D) immune globulin which suppresses the mothers immune system from attacking the Rh+ cells of the fetus.

Question 14

What are SE/CI of Rho(D)

Answer 14

: ↑↓ BP, chills, fever, rash, abdominal pain, nausea, vomiting, injection site reaction (discomfort, induration, redness) joint pain, back pain, acute renal failure, anaphylaxis, if given for ITP also cause hemolysis, decreased hemoglobin, increased bilirubin
Contraindications: hypersensitivity to immune globulins or prior sensitization to Rho(D)

Question 15

When do you treat with Rho(D)?

Answer 15

Given at 28 weeks gestation

Given after trauma to the mother, any procedures during pregnancy, any suspicion of maternal fetal hemorrhage, miscarriage or abortion

Given within 72 hours after delivery if the baby is Rh +

Question 16

What is the idea behind allergen desensitization (allergy shots)?

Answer 16

Increasing amounts of allergen are administered in an attempt to alter the abnormal immune response to that allergen and relieve symptoms

Question 17

How does allergen immunotherapy work?

Answer 17

Thought to generate IgG blocking antibodies that cover the antigen and block it from binding with IgE

May stimulate regulatory Tcells to down regulate the response to that antigen

Question 18

What are the most common allergens in NA that we can treat with immunotherapy?

Answer 18

Pollen, pets, mold, grass, hymenopter (bee stings), ragweed, trees, cockroach, dust mites.

Question 19

What are indications for immunotherapy use?

Answer 19

Failure of medical and avoidance therapy

Symptoms are secondary to the allergen in question AND skin or serum testing to the allergen is positive

Allergy symptoms interfere with daily life

For children with allergic rhinitis, therapy may decrease the development of asthma (decrease the incidence from 45% down to 25%)

Question 20

What are some factors to consider when using immunotherapy

Answer 20

CI in sever or labile asthma and patients on BB. Don’t initiate during pregnancy. >5yo, reliable patient for f/u

Question 21

What is the timeline for immunotherapy and some considerations when giving doses?

Answer 21

Build up phase
1-3 injections per week for several weeks
Maintenance phase
Injections every 2-4 weeks
Duration of therapy
3-5 years
this can be altered if patient is sensitive(slower) or effect is needed sooner(faster)

Question 22

What can be an adverse reaction to immunotherapy and what should you do to be prepared for this?

Answer 22

Local
Will occur in up to 80% of patients
Occurs at the site of the injection
Redness, pruritus, swelling 
Systemic
Will occur in up to 0.25-3.5% of patients
Occurs away from the injection site
May range from mild rhinitis to fatal cardiovascular collapse

Monitor patient for 30min after injection, no exercise 2hr before and after. Have a crash cart with epi, IV antihistamine, glucocorticoids and airway mgmt supplies.

Measure the size of local reactions in cm for immunologist

Question 23

How can you determine the extent of a patients reaction to bee stings?

Answer 23

Measure baseline serum tryptase levels
Baseline levels > 11.4 ng/mL may indicate a mast cell disorder (nml < 11.4)
Chronically elevated levels predict more severe reactions to stings in general, more frequent treatment failure and greater risk of relapse after stopping therapy

Question 24

What is Anti-IgE therapy used for and what is a common medication?

Answer 24

For the treatment of moderate to sever persistent asthma caused by year round allergens and in patients where high dose inhaled steroids fail. Serum IgE levels of 30-700IU/ml. Administered subcut Q 2-4 weeks, $$$$$$

Question 25

How does Anti-IgE therapy work?

Answer 25

It binds to free IgE reducing the amount of mast cell activation and therefore reducing inflammation.