Primary Care Offices Unprepared for Allergen Therapy Emergencies

(Family Practice News) A survey of primary care offices revealed that the majority were not fully equipped to handle adverse reactions to allergen immunotherapy.

“Primary care offices require further education on administration of allergen immunotherapy to ensure adherence to the updated practice parameter, as well as to ensure safety,” Dr. Vinitha Reddy said at the annual meeting of the American Academy of Allergy, Asthma and Immunology.

The telephone survey involved a questionnaire administered to nurses at 43 primary care offices (35 family medicine, 4 pediatric, and 4 internal medicine) that administer allergen immunotherapy (AIT). The practices employed a total 194 physicians, and administered AIT to approximately 500 patients.

The survey assessed adherence to the recommendations in “Allergen immunotherapy: a practice parameter third update,” a joint guideline issued by the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma, and Immunology (J. Allergy Clin. Immunol. 2011;127:S1-55).

The guideline states that allergists’ offices are the preferred setting, but that primary care offices can perform AIT if the appropriate personnel and equipment are available to identify and treat anaphylaxis or other emergencies. The risk is low – approximately 0.2% of patients experience systemic reactions per injection, and deaths occur in just 1 per 2.5 million injections. However, the risk is not nonexistent, said Dr. Reddy, a second-year postgraduate fellow at Pennsylvania State University, Hershey.

Only 53% of the offices reported performing the recommended preinjection health assessment, which should include a determination of the presence of asthma and the degree of asthma control. Only 23% reported measuring peak flow, which is suggested as a method for assessing lung function in asthma patients.

Just 33% of the practices reported routinely having patients wait the recommended 30 minutes following AIT before leaving the office. Another 42% had patients wait just 20 minutes, and the other 25% had patients wait only 10 minutes.

Adverse reactions in the past 6 months, including hives, wheezing, or shortness of breath, were reported by 30% of the offices. None of the nurses reported having had a case of anaphylaxis, Dr. Reddy said.

All of the offices’ nurses said that they felt prepared to handle adverse reactions, and all said that they stock epinephrine, oxygen, and needles. The ability to administer antihistamines, corticosteroids, airway maintenance, and intravenous fluids was reported by 91%, 93%, 93%, and 70% of offices, respectively.

When offered in-service education on the AIT practice parameter, only 42% expressed interest. The other 58% stated that they did not have the time, Dr. Reddy reported.

During the question and answer period, an audience member commented that “it would be interesting” to conduct the same assessment in allergy practices, noting that “it may be about equal.”

Dr. Reddy stated that she had no financial disclosures.

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