Allergens and Allergen Immunotherapy Third Edition, Revised and Expanded edited by Richard F. Lockey Samuel C. Bukantz University of South Florida College of Medicine and James A. Haley Veterans’ Hospital Tampa, Florida, U.S.A. Jean Bousquet Montpellier University Montpellier, France MARCEL MARCELDEKKER, INC. NEWYORK . BASEL DEKKER The second edition of this book was edited by Richard F. Lockey and Samuel C. Bukantz. Although great care has been taken to provide accurate and current information, neither the author(s) nor the publisher, nor anyone else associated with this publication, shall be liable for any loss, damage, or liability directly or indirectly caused or alleged to be caused by this book. The material contained herein is not intended to provide specific advice or recommendations for any specific situation. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data A catalog record for this book is available from the Library of Congress. ISBN: 0-8247-5650-9 This book is printed on acid-free paper. Headquarters Marcel Dekker, Inc., 270 Madison Avenue, New York, NY 10016, U.S.A. tel: 212-696-9000; fax: 212-685-4540 Distribution and Customer Service Marcel Dekker, Inc., Cimarron Road, Monticello, New York 12701, U.S.A. tel: 800-228-1160; fax: 845-796-1772 Eastern Hemisphere Distribution Marcel Dekker AG, Hutgasse 4, Postfach 812, CH-4001 Basel, Switzerland tel: 41-61-260-6300; fax: 41-61-260-6333 World Wide Web http://www.dekker.com The publisher offers discounts on this book when ordered in bulk quantities. For more information, write to Special Sales/Professional Marketing at the headquarters address above. Copyright © 2004 by Marcel Dekker, Inc. All Rights Reserved. Neither this book nor any part may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, microfilming, and recording, or by any information storage and retrieval system, without permission in writing from the publisher. Current printing (last digit): 10 9 8 7 6 5 4 3 2 1 PRINTED IN THE UNITED STATES OF AMERICA CLINICAL ALLERGY AND IMMUNOLOGY Series Editors MICHAELA. KALINER,M.D. Medical Director Institute for Asthma and Allergy Washington, D. C. RICHARDF. LOCKEY,M.D. Professor of Medicine, Pediatrics, and Public Health Joy McCann Culverhouse Professor of Allergy and Immunology Director, Division of Allergy and Immunology University of South Florida College of Medicine and James A. Haley Veterans Hospital Tampa, Florida 1. Sinusitis: Pathophysiology and Treatment, edited by Howard M. Druce 2. Eosinophils in Allergy and Inflammation, edited by Gerald 3. Gleich and A. Barry Kay 3. Molecular and Cellular Biology of the Allergic Response, edited by Arnold 1. Levinson and Yvonne Paterson 4. Neuropeptides in Respiratory Medicine, edited by Michael A. Kaliner, Peter J. Barnes, Gert H. H. Kunkel, and James N. Baraniuk 5. Provocation Testing in Clinical Practice, edited by Sheldon L. Spector 6. Mast Cell Proteases in Immunology and Biology, edited by George H. Caughey 7. Histamine and HI-Receptor Antagonists in Allergic Disease, edited by F. Estelle R. Simons 8. lmmunopharmacology of Allergic Diseases, edited by Robert G. Townley and Devendra K. Agrawal 9. Indoor Air Pollution and Health, edited by €mil J. Bardana, Jr., and Anthony Montanaro 10. Genetics of Allergy and Asthma: Methods for Investigative Studies, edited by Malcolm N. Blumenthal and Bengt Bjorksten 11. Allergic and Respiratory Disease in Sports Medicine, edited by John M. Weiler 12. Allergens and Allergen Immunotherapy: Second Edition, Revised and Expanded, edited by Richard F. Lockey and Samuel C. Bukantz 13. Emergency Asthma, edited by Barry 15.Brenner 14. Food Hypersensitivity and Adverse Reactions, edited by Marianne Frieri and Brett Kettelhut 15. Diagnostic Testing of Allergic Disease, edited by Stephen F. Kemp and Richard F. Lockey 16. Inflammatory Mechanisms in Allergic Diseases, edited by Burton Zweiman and Lawrence B. Schwartz 17. Histamine and HI-Antistarnines in Allergic Disease: Second Edition, Revised and Expanded, edited by F. Estelle R. Simons 18. Allergens and Allergen Immunotherapy: Third Edition, Revised and Expanded, edited by Richard F. Lockey, Samuel C. Bukantz, and Jean Bousquet ADDITIONAL VOLUMES IN PREPARATION Graft-vs.-Host Disease: Third Edition, edited by James L. M, Ferrara, Kenneth Cooke, and H. Joachim Deeg To our coeditor, Samuel C. Bukantz—the compleat teacher, author, editor, researcher, and clinician R.F.L J.B. Series Introduction As I look at my library, the most obviously well-read book is the first edition of Allergen Immunotherapy. That book helped me establish plans for private practice and served me very well. The second edition, Allergens and Allergen Immunotherapy, provided many useful additions to my treatment plans for immunotherapy. Now, there is a third edition, extending the knowledge and applications of the first two books. I might suggest that this book be required reading for all practitioners who prescribe allergy immunotherapy. Where else is theory and practice in such an important subject so well combined and in such useful detail? This book takes the principles of allergens, immunotherapy, and the treatment of allergic disease to a very practical but evidence-based level. The background for immunotherapy is provided in historical and immunological terms, as well as in aerobiological principles. These chapters provide a solid basis for understanding why we give immunotherapy. Unless one understands the allergens, their importance, and how to decide which is causing patient-related disease, then proper decision-making regarding immunotherapy cannot be applied. Chapters on specific aller- gens are essential to practitioners prescribing immunotherapy. As part of my practice, I see patients who have had unsuccessful treatments with allergen immunotherapy. Many of the patients were poor candidates for allergy immunotherapy from the beginning and others were given improper mixes of allergens, administered incorrectly. This book addresses these issues using a very practical approach, detailing how and when to give immunotherapy, for how long, and to which patients. Potential problems encountered in the course of immunotherapy are described and solu- tions presented. One of the major advances in prescribing immunotherapy has been the recognition that the constitution of the mixtures and preserving allergenicity are essential to efficacy, and that using sufficient allergen concentration is a minimal prerequisite for long-term benefit. Chapters detailing allergen preparation and administration offer information that is essential to the decision-making process, and these concepts have changed over the past 10 years. Experienced allergists will benefit from re-reading these chapters. The range of clinical problems for which immunotherapy is an option is described in detail. The usefulness of immunotherapy in allergic rhinoconjunctivitis and asthma, as well as in hymenoptera sensitivity, is presented. Other desensitizations, including drug allergy, are outlined, as are novel treatments such as the newly introduced monoclonal v vi Series Introduction anti-IgE therapy. This is not a clinical allergy text, but it raises and answers the questions of who should get immunotherapy and what to expect. Other forms of treatment besides immunotherapy and their use along with immunotherapy are covered, as are potential future extensions of this treatment. There is limited use of sublingual-swollen immuno- therapy in the United States; however, this is a popular form of treatment for mild allergic disease in Europe and the data are presented here. I find this text to be compelling in its comprehensive approach to the most impor- tant disease-modifying treatment available for allergic rhinitis and allergic asthma. It should be read by allergists who want to know where we are with proper immunotherapy and where we are going with this treatment modality. It should be read by those clinicians who use alternative approaches to immunotherapy in order to recognize why allergen immunotherapy is effective and what goes into proper preparation and administration of effective immunotherapy. And, it should be read by clinicians whose patients are receiving immunotherapy to be certain that the immunotherapy prescribed has been ordered appropriately and is being administered correctly. I am pleased to add this volume to our series of venerable books. Michael A. Kaliner Preface The first edition of Allergen Immunotherapy, published in 1991, contains 13 chapters. The second edition, Allergens and Allergen Immunotherapy published eight years later, expanded to 33 chapters in order to more precisely define the biochemical and molecular characteristics of the allergen groups, the methods of their manufacture and standardization, and the techniques of their administration in the treatment of allergic diseases. Global contributions to the understanding of the basic mechanism of the allergic reaction has improved the efficacy of immunotherapy of allergic disease. Many of the scientific contributions have come from around the world, and this prompted the addition of Dr. Jean Bousquet of Marseilles as co-editor. Dr. Bousquet, well-known for his studies of the immunotherapy of allergic diseases and asthma, has been influential in the selection of additional investigators, whose