What is a maximal allergy treatment regimen?

From the Guidelines

A maximal allergy treatment regimen should include an epinephrine auto-injector, education on avoidance of allergen, and consideration of referral to an allergist, with adjunctive treatment including H1 antihistamine, H2 antihistamine, and corticosteroid as needed. This comprehensive approach is based on the guidelines for the diagnosis and management of food allergy in the United States, which emphasize the importance of a multi-faceted treatment plan 1. The regimen should be tailored to the individual patient's needs, taking into account the severity of their symptoms and any co-existing medical conditions.

Key components of the maximal allergy treatment regimen include:

• Epinephrine auto-injector prescription and instructions for use
• Education on avoidance of allergen to prevent exposure and reduce symptoms
• Consideration of referral to an allergist for further evaluation and treatment
• Adjunctive treatment with:
  • H1 antihistamine, such as diphenhydramine, every 6 hours for 2-3 days
  • H2 antihistamine, such as ranitidine, twice daily for 2-3 days
  • Corticosteroid, such as prednisone, daily for 2-3 days

It is essential to note that these treatments often occur concomitantly, and are not meant to be sequential, with the exception of epinephrine as first-line treatment. The goal of this regimen is to provide effective symptom control while minimizing the risk of adverse effects. By prioritizing the patient's safety and well-being, healthcare providers can help to reduce morbidity, mortality, and improve quality of life for individuals with severe allergies.

From the FDA Drug Label

1 INDICATIONS & USAGE Adrenalin® is available as a single-use 1 mL vial and a multiple-use 30 mL vial for intramuscular and subcutaneous use. Emergency treatment of allergic reactions (Type I), including anaphylaxis, which may result from allergic reactions to insect stings, biting insects, foods, drugs, sera, diagnostic testing substances and other allergens, as well as idiopathic anaphylaxis or exercise-induced anaphylaxis.

5 Allergic States Control of severe or incapacitating allergic conditions intractable to adequate trials of conventional treatment: Seasonal or perennial allergic rhinitis Bronchial asthma Contact dermatitis Atopic dermatitis Serum sickness Drug hypersensitivity reactions

The maximal allergy treatment regimen is not explicitly stated in the provided drug labels. However, based on the indications for epinephrine (IM) and prednisone (PO), a maximal allergy treatment regimen may involve:

• Emergency treatment with epinephrine (IM) for anaphylaxis or severe allergic reactions 2
• Control of severe or incapacitating allergic conditions with prednisone (PO) for conditions such as seasonal or perennial allergic rhinitis, bronchial asthma, or drug hypersensitivity reactions 3 It is essential to note that the treatment regimen should be individualized and based on the specific condition and patient needs.

From the Research

Definition of Maximal Allergy Treatment Regimen

A maximal allergy treatment regimen can be considered as the most comprehensive and intensive approach to managing allergies, particularly in cases of severe or life-threatening reactions.

Characteristics of Maximal Allergy Treatment Regimen

• Involves the administration of gradually increasing quantities of specific allergens to patients with IgE-mediated conditions until a dose is reached that is effective in reducing disease severity from natural exposure 4
• May include allergen immunotherapy, which has been shown to be effective in the treatment of stinging-insect hypersensitivity, allergic rhinitis or conjunctivitis, and allergic asthma 4
• Requires immediate availability of a health care professional capable of recognizing and treating anaphylaxis, and an observation period of 20 to 30 minutes after injection 4
• May involve the use of epinephrine autoinjectors, glucocorticosteroids, and histamine H(1)-antagonists in the treatment of anaphylaxis 5
• Requires careful consideration of the patient's medical history, including the use of beta-adrenergic blocking agents, which may mask early signs and symptoms of anaphylaxis 4, 5

Treatment Approaches for Polyallergic Patients

• Single-allergen immunotherapy is recommended in polyallergic patients in whom one of the relevant allergens is clearly responsible for the most intense and/or bothersome symptoms 6
• Parallel 2-allergen immunotherapy or mixed 2-allergen immunotherapy is indicated in polyallergic patients in whom two causal relevant allergens have a marked clinical and QoL impact 6
• Mixing of allergen extracts may be considered, as long as the mixture is technically feasible, allowed from a regulatory standpoint, and the allergen doses are reduced in proportion to the number of components but are still at concentrations with demonstrated efficacy 6

Strategies to Minimize Adverse Reactions

• Care in the preparation of allergy extracts for treatment 7
• Use of modified extracts 7
• Location for administration of SCIT and SLIT 7
• Risk factors for systemic reactions 7
• Use of premedication 7
• Prescription of epinephrine autoinjectors 7
• Adjustments in dose for pollen seasons, interruptions in treatment, and for local and systemic reactions 7