SCIT: Standard schedules, administration techniques, and monitoring
- Harold Nelson, MD
Harold Nelson, MD
- Professor of Medicine
- National Jewish Health
- University of Colorado Denver School of Medicine
There is significant variation in the way subcutaneous immunotherapy (SCIT) is administered around the world, including differences in schedules for injections, safety precautions, training requirements, and approaches to documentation. Over the past few decades, professional allergy societies in the United States have made attempts to reduce variations in practice across the United States and identify best practices. Practice parameters for SCIT have been published and the practices described in this topic review are consistent with American guidelines .
This topic will review conventional schedules for the administration of SCIT, focusing on those used to administer inhalant allergens. Adjustments in schedules in response to adverse effects, injection techniques, safety requirements for facilities at which immunotherapy is given, documentation, and patient monitoring will also be discussed. Accelerated schedules for SCIT (including rush, cluster, and ultrarush) and schedules for Hymenoptera venom immunotherapy are reviewed elsewhere. (See "Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring", section on 'Choice of protocol'.)
SCIT schedules differ in the number of injections per visit, number of visits per week, and the rapidity with which the patient reaches the maintenance dose. Conventional immunotherapy schedules involve one to three injections per week during a build-up phase that lasts a number of weeks, followed by a maintenance phase, during which injections are given every two to four weeks over a period of years.
Build-up phase — There are faster and slower versions of conventional schedules. The clinician may choose a schedule with a slower (more gradual) build-up for the patient at increased risk for a systemic allergic reaction to the immunotherapy itself. The primary advantage of slower schedules is the reduced risk of systemic allergic reactions. An example of a conservative build-up schedule is provided (table 1) .
Within the spectrum of conventional schedules, more conservative schedules are appropriate for patients with any of the following characteristics:
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- CONVENTIONAL SCHEDULES
- Build-up phase
- Maintenance phase
- Total duration of therapy
- ADMINISTRATION OF INJECTIONS
- Safety precautions at every visit
- Injection technique
- TRAINING AND PREPARATION FOR MANAGING SYSTEMIC REACTIONS
- Personnel and site
- Equipment and medications
- ADVERSE REACTIONS TO IMMUNOTHERAPY
- Local reactions
- - Prevention and treatment
- Relationship between local and systemic reactions
- Systemic reactions
- DOSE ADJUSTMENTS
- Following systemic allergic reactions
- Following large local reactions
- Missed injections
- Restarting immunotherapy
- New vials
- New allergen added to therapy
- Change in supplier of allergen extracts
- High pollen and mold seasons
- Consent form
- SCIT administration form
- Objective testing
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS