Rush Immunotherapy Protocol

Allergy Center USA Anytown, USa

Rush Immunotherapy Protocol Patient: Date of Birth: Date: Allergen:

Time (actual) Volume Dilution Arm Symptom FEV1 Initials (min) (cc) 0 0.30 1:100,000 A0 30 0.10 1:10,000 A1 60 0.30 1:10,000 A1 90 0.05 1:1000 A2 120 (2h) 0.15 1:1000 A2 150 0.30 1:1000 A2 180 (3h) 0.05 1:100 A3 210 0.10 1:100 A3 240 (4h) 0.30 1:100 A3 270 0.50 1:100 A3 300 (5h) 0.05 1:10 A4 330 0.10 1:10 A4 360 (6h) 0.30 1:10 A4

 Premedication – 2 days prior begin taking, day of, and one day after o Prednisone 30mg twice a day o Ranitidine 150mg twice a day (Zantac) o Loratadine 10mg once a day (or Cetirizine, Fexofenadine) . Claritin, Zyrtec, Allegra, Xyzal, Clarinex

 Check baseline spirometry prior to visit  Check baseline spirometry morning of procedure  Check spirometry or peak flow before each injection  Alternate arms for each injection  Examine and document reactions before next injection  Observe for 2 hours after last injection

 CPT 95180, rapid desensitization procedure, document units of TIME / hours  CPT 94070, multiple spirometry  CPT 95117, allergy injection (multiple)