Topics in Allergy
Immunotherapy (Allergy Shots) For Airborne Allergens
Immunotherapy (allergy shots) may be a treatment option for your (or your child's) allergic problems. If you are considering immunotherapy it is important for you to understand the purpose and expectations of immunotherapy, the general program (schedule), the risks, and alternate treatment options before making a decision about starting allergy shots.
The purpose of immunotherapy is to make the patient less sensitive to one or more specific allergens (pollens, dust mites, molds, animals, bee venoms, etc.). Immunotherapy is often considered if allergic symptoms are not controlled by other measures, if medications are causing side effects or if your symptoms require prolonged use of medication.
An extract is prepared according to a patient's specific sensitivities and may be given only to that individual patient. Injections are given at weekly or twice weekly intervals in gradually increasing doses. When the highest dose (maintenance dose) is reached, the shots may be quickly lengthened to a monthly schedule. It usually takes 5-8 months to reach the maintenance dose. The total duration of immunotherapy is 3-5 years, at which time the allergy shots can be stopped. The improvement from allergy shots usually continues without additional injections for many years and often for life. A small number or patients, however, have a recurrence of symptoms when the allergy shots are stopped and may choose to take shots for longer periods.
Most patients who receive allergy shots have significant improvement. The probability of improvement varies with the type of allergy being treated. Over 99% of those allergic to bee venoms improve. About 90% with pollen allergies improve. Dust Mite and animal allergies typically respond well to allergy injections. Molds are somewhat more difficult to treat. Your probability of improvement can often be estimated by your history and allergy evaluation. The degree of improvement varies. A few patients have essentially complete resolution of their allergic problems. Most find the degree of allergic problems is lessened but they may still need medications and need to minimize exposure to allergens. When medications are still required, less medication is needed, medications are more effective and are needed for shorter times. A small number of people do not respond to allergy shots and if this is the case the injections are usually stopped after 1-2 years. We consider the role of immunotherapy in the treatment of allergic disease to be an adjunct, not a substitute, for other measures such as allergen avoidance and medications.
The disadvantages of allergy shots include the involved schedule especially in the first few months, the fact it takes several months or longer to assess your response, the cost, and the possibility of an allergic reaction to the allergy shot. We try hard to minimize difficulties of receiving allergy shots. Our office is open many hours during the week (see below). You do not need an appointment to come in for your shot and you do not need to come on the same day or at the same time. You will have a bar coded ID card you slip in front of a scanner that immediately "checks you in," and notifies the nurse you are here. The average time between scanning your card and receiving the shot is 2-3 minutes (our computer tracks this). You then need to wait in the office for 30 minutes for the nurse to check the injection site and to monitor for shot reactions. The cost of allergy shots is often outweighed by reduced medication costs.
It is possible to have a SYSTEMIC REACTION to allergy shots. These usually occur within minutes after an injection (but may rarely occur up to several hours later) and are easily treated but require immediate attention. The reactions may involve itching, rash or swelling in places other than the injection site, hay fever symptoms, trouble breathing, and faintness due to dropping blood pressure. These reactions are very rare and usually reverse quickly if treated but have the potential of being serious and even fatal. You should immediately notify the nurse if you have symptoms of a reaction. Immediate treatment is most effective in stopping the reaction. Serious reactions are almost unheard of except for patients with the following risk factors:
1. Patients on beta blockers-these are medications used for heart and blood pressure problems, for migraine headaches and in eye drops for glaucoma. Other physicians may not be aware of problems with beta-blockers and allergy shots. NOTIFY OUR OFFICE OF ALL CHANGES IN MEDICATIONS FROM ALL DRS.
2. Patients receiving an allergy shot during a significant asthma flare. Tell us your asthma is flaring and we will restabilize it before giving the injection.
3. Leaving the office too early. Shot reactions are easy to treat here, much harder if you are not in the office.
Because of this we do not allow allergy shots to be given outside of a physicians office and do not give them here unless Dr. DeYarman is in the office.
In addition to these precautions we recommend:
*You do not receive your shot if you have a fever.
*Avoid strenuous exercise for 2 hours after a shot.
*Some patients wish to have injectable adrenalin (EpiPen) available in case they experience a reaction after leaving the office.
Despite these concerns, shot reactions are rare and nearly always simple to treat.
LOCAL REACTIONS are common after allergy shots and consist of redness, swelling and itching at the injection site. These may be immediate or delayed in onset and may last for hours to a day or more. If local reactions are excessive, report the reaction to the nurse before your next injection. You may treat the local reactions with ice applied to the injection site, a strong (prescription) cortisone cream or ibuprofen by mouth if you are not aspirin sensitive..
Allergy shots may be given during PREGNANCY. Please notify us if you are pregnant as minor changes in your shot program may be needed and we should review your overall allergy management program.
Please notify us if any questions or concerns arise during the course of your immunotherapy program.
PRACTICAL POINTS TO REMEMBER:
1. Allergy shots are given in our office in Medford during the following hours:
Mon: 8:30 AM - 11:30 AM & 1:30 PM - 4:30 PM
Tue: 8:30 AM - 11:30 AM & 1:30 PM - 5:30 PM
Wed: 8:00 AM - 11:30 AM & 1:30 PM - 4:30 PM
Thu: 8:30 AM - 11:30 AM & 1:30 PM - 4:30 PM
At times our office is closed on the usual shot days. These closures are posted on the outside front door to the office and at the check in computer. We make every attempt to post these notices at least a month ahead. In addition our schedule for allergy shots and any changes in our schedule may be found on the Contact & Schedules page of our website (Contact & Schedules). Just bookmark the schedule page and you can check in an instant to make sure we will be in the office when you arrive. You are also welcome to call to make sure we are open before you come for your allergy shot. Patients who live far away can receive injections in other physicians offices.
2. You do not need an appointment for your allergy shot. When you come for your first allergy shot let our staff know it is your first injection. They will show you how to check in for your shots. For all subsequent injections you just place your bar-coded ID card under the scanner at the shot check in computer and all of your information will appear on the computer, the computer will tell you how many people are ahead of you and the nurse will call you within a few minutes. You then need to wait for 30 minutes and check with the nurse before leaving the office. During the 30 minute waiting time you may rescan your ID card and the computer will tell you how long you have waited.
3. Wear short sleeves for easy access to the arm for allergy shots.
4. Antihistamines the day of the allergy shots are encouraged to reduce local reactions.
5. You should not be taking BETA BLOCKERS while on allergy shots. Beta blockers are medications used for blood pressure, heart problems, migraine headaches, and in eye drops for glaucoma. Other physicians may not know you should not be on beta blockers while you are on allergy shots. NOTIFY OUR NURSES OF ALL NEW MEDICATIONS PRESCRIBED BY ANY OFFICE.
6. Asthma that is unstable is a risk factor for allergy shot reactions. If your asthma has not been well controlled, please notify our nurses and we will restabilize your asthma and adjust your shot dose. Severe flare-ups of hay fever may also be a risk factor and you should notify us of this before receiving an allergy shot.
7. You should not exercise for 2 hours after an allergy shot.
8. Large or uncomfortable local reactions may be treated with ice applied to the shot area, application of a strong (prescription) cortisone cream, or oral ibuprofen if you are not sensitive to aspirin or ibuprofen.
9. Cost of Immunotherapy. Charges for medical treatments are quite confusing. Each medical treatment has a code (CPT Code) and charges are made by the CPT code. We are required to have stated charge for each CPT code but each insurance company (we deal with hundreds) has their own formula and set of rules to determine what they pay for the CPT code. Consequently our "charge" and what we are paid can be quite different and this varies widely from one company to another. Some pay a reasonably high percentage, others pay less than your actual costs.
Allergy immunotherapy has two associated costs.
THE FIRST IS THE COST OF THE ANTIGEN (SHOT MATERIAL). We mix approximately a years material at a time. When you start allergy shots you build through 4 increasingly strong vials (theoretically you will use 4 vials in the first year). Then you are on a maintenance dose and stay with the strongest vial (theoretically 1 vial per year).
The antigen is billed per vial with 10 units per vial. This does not always make sense but is consistent with the rules we must live with.
THE USUAL COST FOR ANTIGEN FOR THE FIRST YEAR IS:
**IF YOU HAVE ONE ANTIGEN EXTRACT-$700 (CPT CODE 95165 @ 40 UNITS-10 UNITS PER VIAL-4 VIALS OF EXTRACT).
**IF YOU HAVE TWO ANTIGEN EXTRACTS-$1400 (CPT CODE 95165 @ 80 UNITS-10 UNITS PER VIAL-4 VIALS OF EACH OF THE TWO EXTRACTS).
THE USUAL COST FOR ANTIGEN FOR SUBSEQUENT YEARS IS:
**IF YOU HAVE ONE ANTIGEN EXTRACT-$175 (CPT CODE 95165 @ 10 UNITS-10 UNITS PER VIAL-1 VIAL OF EXTRACT).
**IF YOU HAVE TWO ANTIGEN EXTRACTS-$350 (CPT CODE 95165 @ 20 UNITS-10 UNITS PER VIAL-1 VIAL OF EACH OF THE TWO EXTRACTS).
he vials of antigens have a shelf life once they are mixed.
Vials 1 & 2 have an expiration date 6 months after they are mixed. Vials 3 & 4 have an expiration date 12 months after they are mixed. Consequently it is worthwhile to begin allergy shots soon after they are mixed and to be fairly regular while building the shots to avoid having to remix expired antigen or dropping back to prior vials because of long time periods between shots.
THE SECOND COST IS THE COST OF THE INJECTION.
AN ALLERGY INJECTION WITH ONE ANTIGEN IS $25 (CPT 95115).
AN ALLERGY INJECTION FROM EACH OF 2 ANTIGENS (2 SHOTS GIVEN AT THE SAME TIME FROM DIFFERENT EXTRACTS IS $33 (CPT 95117).
I know this is all very confusing but unfortunately the rules from the insurance companies and government are inherently confusing. If you have questions about the billing of allergy shots please check with the front desk. Our office staff is quite familiar with the intracies of insurance company rules.
(The above figures are based on 2002 information and may change from year to year).