Allergen Immunotherapy Is Not For The Faint Of Heart

Last week I had my first post-RUSH shots.  And my first major reaction.  I'd been warned that the first shots can trigger a reaction because you go into it with nothing more than one Xyzal tablet.  Plus, the ragweed count was very high last week.  This combination resulted in six days and nights of swelling, itching and pain, despite treating it with antihistamines, ice and Motrin.  My upper arms, from shoulder to elbow, were so swollen I looked like a weight lifter.  And not in a good way.  The skin was tight and an angry shade of red.  Thankfully, I did not have to use my Epi Pen. 

As of last night, I was convinced I would not proceed with the treatment.  I cannot deal with that sort of constant agony. 

But I woke up today full of resolve and am now sitting in the doctor's office with an ice pack on my upper arm.  I need to press on.  This week, they've given me half the dose and provided me with more medication to deal with the reaction.  I am hopeful I don't have the same experience.  I need to keep my eyes on the horizon - one day, I will be allergy free.

Read my other posts about Allergen Immunotherapy here.

My RUSH Immunotherapy Experience

pollen

A few months ago, I wrote a piece about having skin testing done for my allergies. My allergies have been a lifelong pain in the neck and this past Spring was my worst bout yet. My goal was to determine what I am allergic to and to what extent so that I could figure out what to do about it.

Through testing, I was able to pinpoint exactly what causes my reactions and plan for it rather than just react to it. 

For instance, certain weeds, grasses and trees are active at certain times of the year in this area of the US, which explains why certain times of the year are worse for me than others. This past year I was congested from January to May and had three sinus infections.  I was constantly playing catch up, probably with the wrong medications. 

Also: dogs, cats and horses absolutely do me in.  As a result, I have to ask if there are pets at someone's home before I determine if I can visit them. If the answer is yes, I can't go unless I have time to dope myself up on antihistamines, then deal with two recovery days.  It puts a dent in our social life.

Once I determined what my sensitivities are, I had another decision to make. Should I continue treating my allergies with nasal spray and oral antihistamines or begin immunotherapy to permanently eradicate my sensitivities? I hate taking medication and antihistamines can make me sluggish.  Shot therapy is a time commitment (years of weekly, then bi-weekly, then monthly shots), but the idea of never again suffering from these allergies is very appealing.

After I determined I would undergo shot therapy, the doctor asked me if I'd like to do RUSH treatment.  His office has done more RUSH treatments than any other in the country - over 3,000 so far.  RUSH is a method of kick-starting your immunotherapy treatment. You spend one day getting shots every thirty minutes, while being heavily dosed with antihistamines so your body can handle it. This treatment gives you a one year jump-start on the shot therapy. Within a few months, I could feel allergy free and the total duration of my shot therapy would be one year less (maybe four years instead of five). My insurance covers it, so I signed up.

In anticipation of today's RUSH treatment, I was given a packet of information, prescriptions and medications.  I was told to dose myself with certain medications the day before, the day of and the day after, as follows:

AM Medications:

• Prednisone 10 mg, 3 tablets with meal (steroid that prevents inflammation in vital organs - the most important drug in the cocktail)
• Zantac 75 mg, 2 tablets or 150 mg 1 tablet (typically used for sour stomach, this is actually in the mix because it contains a certain antihistamine)
• Xyzal 5 mg, 1 tablet (another antihistamine)

PM Medications:

• Prednisone 10 mg, 3 tablets with meal
• Zantac 75 mg, 2 tablets or 150 mg 1 tablet
• Singulair 10 mg, 1 tablet at bedtime (an asthma medication to keep the lungs clear)

I had to fill a prescription for two Epi Pens. An Epi Pen is an epinephrine auto-injector for anaphylatic emergencies. This made me nervous but I was told that the likelihood of having to use it is in the low single digits.  It's just best to be prepared. The reason they prescribe two is that if a person ever needs to use it, one out of three people need two shots rather than just one.

RUSH Day
I arrived for RUSH treatment at 8am and was asked if I'd taken my medication, if I am pregnant (no), what other medications I'd taken in the prior two days, and was administered a breath test to ensure my lungs were nicely clear.

I was then ushered into a lounge where I was to spend the day. Wifi, a recliner, a mini fridge and cable TV made it quite comfortable. Though the room accommodates two patients, the other patient canceled so I had a very nice nurse named Libby dedicated to just me all day long.

The RUSH nurse set up a saline lock peripheral IV access point on my left arm (a needle with a valve so they can quickly administer liquid antibiotics if needed).   I was explained what would happen.  I'd get 12 to 14 shots (the serum to cover all of my allergies comes in two vials because they can't fit them all in one - yay for me - so two shots per round), two at a time, one in each upper arm, spaced 30 minutes apart.  Each round carries an increased concentration.  The last round (shots 13 and 14) carry a concentration the represents all of the prior shots combined.  If I have a reaction after the sixth round, I won't get the last two shots. She'll take my blood pressure, my pulse and listen to my chest before every round.

Here's my journal of the day:

8:30am - Nurse put the line in my arm and taped it up.  It's just for emergency use.  I was told that was as painful as the day would get.  I'm hoping she's right!

8:45am - I was given my first two shots. Almost painless.

8:55am - I seemed to feel bugs crawling on me but that could be my overactive imagination.  The sensation passes. The doctor pays a visit and says he'll check back.

9:15am - Round two of shots. Still okay.

9:45am - Round three of shots. Feeling fine.

10:15am - Round four done.  Still fine.

10:40am - Lips twitching on and off but no other symptoms.  Proceeding.

10:45am - Round five done.  Feeling fine.  Lips still twitching.  Nurse probably thinks I'm crazy but she ran it by the doctor and he decided to give me some liquid antihistamines (more Xyzal) to be on the safe side.

11:15am - Round six done.  Twelve shots so far.  Feeling fine.  Doc came in and said the last two shots won't be for an hour.  If I'm in as good shape then as I am now, he'll go forward with the next two shots.  But if I'm not, no big deal.  The day has been a success even if we stop here.  If we do get the last two shots in, they represent one round during my initial weekly course.  I'm optimistic we can get those next two shots in and save some time later.

12:15pm - Still feeling good.  Blood pressure, lungs, pulse good.  No hives, redness.  We're going forward with the last two shots.  After this, they'll take my blood pressure, pulse and listen to my lungs every 30 minutes for three hours.  If I'm going to have a reaction, it'll probably be in the next hour.

1:00pm - They had me watch a DVD about how to use an Epi Pen properly.   Just in case.  (Interesting fact: don't leave the Epi Pens in the car in hot weather.  High heat lessens their efficacy.)  Any use of the Epi Pen also means an automatic trip to the ER.  Oh joy.

3:00pm - No reaction.  Doctor gave me a 110 out of 100 on the day :)  I'm good to go.

All of the shots were marked on both arms.

I'll take another round of medications tonight and two more doses tomorrow.

In the next 24 hours, I can expect some mild reactions to the RUSH therapy (treat with Benadryl), including:

• local swelling, itching, or redness at the injection site
• itching or swelling of the eyes
• congestion or runny nose
• itchy/scratchy throat

Bad reactions in the next 24 hours are anaphylaxis, for which I must use the Epi Pen and call 911:

• heavy generalized itching or hives (if they're on the surface, they're on the inside and could eventually lead to swelling of the airways)
• a flushed appearance with or without facial swelling (though could just be the steroids rather than anaphylaxis - first take Benadryl and see if that helps)
• tightness in the throat with a change in voice (like laryngitis)
• wheezing/coughing
• severe shortness of breath
• nausea/vomiting/abdominal cramping
• shock (when the blood pressure drops to dangerously low levels - signs are light-headedness, dizziness, lethargy, confusion, pale clammy skin, heart pounding like it's coming out of your chest (pounding heart could be steroids, heavy pounding could be shock)
• loss of consciousness

I return in one week for my first weekly shot.  I have to take a dose of Xyzal before that first shot and wait an hour in the office to make sure I don't have a bad reaction.  Apparently, there's a higher probability of reaction after that first shot.  That begins 3 months of weekly shots (or twice a week to speed the process if I can fit it in my schedule), then every other week for 6 months, then monthly shots thereafter.  The shots will ramp up in concentration over the next few months.  Then I'll move up to the highest concentration (called a "maintenance dose") and stay there for the monthly treatment for several years.

On "shot days" I need to take a Zyrtec or some other long-lasting antihistamine in order to counteract any local swelling and itching.  I'll also need to keep the Epi Pens with me at all times, just in case of reaction. 

All in all, a day well spent.

Read my other posts about Allergen Immunotherapy here.

Skin Allergy Testing: What's Involved and What I Learned

I've been an allergy sufferer for as long as I can remember.   I can't be around cats, dogs, rabbits, horses - any animals, really, without having a major problem.  And I had seasonal allergies.

Since moving to Texas three years ago from the east coast, my allergies have often been atrocious.  This year, my nose has been nothing but a source of agony since February, which is the last time I was actually able to use it to breathe.  Nothing has worked.  Zyrtec, Claritin, Claritin-D, Benadryl, Tylenol Sinus, Sudafed, you name it.  Nothing worked and whatever I took left me feeling groggy.  I'd wake up with a puffy face, stuffy nose and crusty eyes almost every day.  Visine allergy eye drops became part of my daily routine.  Bad bouts turned into sinus infections.  My symptoms became worse whenever I was outside for long spells (an hour or more) but being outside is unavoidable.  I'm a gardener, a parent of energetic children, and a runner.  I can't avoid the outdoors.  So I finally called an allergist to see if I could find some effective relief.

The first thing they did was test my lung capacity, to ensure that the problem didn't include asthma.  No problem with my lungs.  Then they had me blow my nose into a piece of wax paper and hand over the sample.  Then I was examined by the doctor.  He agreed that given my active lifestyle, it would be impractical to avoid going outdoors.  He told me I should have skin testing done to figure out what, specifically, I am allergic to.  This will help me better understand my seasonal challenges and plan for them, rather than being caught off guard.  He gave me a sample of Veramyst nasal mist, scheduled me for skin testing the next week and gave me guidelines on what what medications to avoid until then so they could get clear results.

The following Monday, I arrived at the allergist, prepared to stay there for 1 1/2 to 2 hours.  The first thing the nurse did is give me two "control" pricks - one of histamine and one of saline.

A few minutes later, the histamine welt appeared (see reddish bump toward top) while the saline prick (below it) had no reaction.  We were able to proceed to the skin testing.

That's when I realized they were going to give me 54 pricks, testing a variety of the allergens typically found in north Texas - dust mites, animals, molds, trees, grasses and weeds.  54.  Gulp.

I wore a hospital gown open in the back and lay on my stomach on the exam table.  The nurse swabbed my back, applied tape with numbers on it and then pricked the appropriate allergen next to the numbers taped to my back.  A simple way to organize them.  The pricks were practically painless.  That was the good news.  But seconds later, the allergens that give me a problem started to REALLY itch.  I mean, I was huffing and puffing in that exam room, trying to use Lamaze breathing to help me cope.  I was unsuccessful.  So I pulled out my iPhone and did my best to distract myself.

Here you can see that the following gave me a problem: dust mites (1, 2), all animals (3, 4, 5), some of the trees (21, 22, 32, 33, 35), virtually all grasses (37 - 43), and a few weeds (46, 48).  The nurse measured the diameter of my welts to determine the severity of my sensitivities.  My biggest sensitivities are to animals and grasses. 

The doctor looked at the results and decided to retest a few suspicious results (more pricks to my upper arm) and determined that the original results were correct.

I got dressed and went to another room to consult with the doctor.  He was able to tell me what months of the year each of my sensitivities would be a problem.  He also told me that I am not allergic to the grass in my own backyard, which is well manicured.  Rather, I am allergic to tall grasses - grasses that are allowed to flower and distribute pollen.  I live in the countryside, so there's a lot of tall grass around.  It's also quite windy here in Tornado Alley, so Cedar pollen blows up from the south year-round.  Grass pollen also blows up from the south when it flowers earlier there than it does here - this lengthens the duration of my grass allergies.  So, Fall and Spring are ultimately my worst seasons - but particularly Spring.

He took quite a bit of time with me, which I really appreciated.  I told him I am the product of a highly allergic mother and a father who also has some allergies.  My mother is highly allergic to mold, among other things, so I was surprised to see that this isn't a problem for me.  He informed me that we can inherit an allergic gene from our parents, but what sort of allergies we develop depends on what we are exposed to as children.  Since my mother really suffered from mold, she was very careful with our house while I was young and I was rarely exposed to it.  I did, however, spend a lot of time outdoors as a child and we had many animals.  So there you go!

Then we discussed a plan of action.  I have two alternatives:

1. Continue to treat it with nasal mist, which worked remarkably well for me over the course of one week.  My nose is back to normal and I've noticed a dramatic and steady improvement in my overall itchiness and eyes.  
2. Start shot therapy to desensitize my body to these allergens, permitting me to one day be completely free of them and any medication I'm now taking to control them.  I have to say, despite the inconvenience of weekly (in the beginning) shots, the idea of one day being allergy-free is extremely appealing.  This is typically a 5 year process (weekly shots year 1, every other week year 2, monthly years 3-5) but can be accelerated to 4 years by doing a 1-day "RUSH".  This involves being given multiple allergy shots over the course of one day with an RN staying with you the whole time to ensure nothing goes wrong.  You are given antihistamines, etc, the day before, the day of and the day after the RUSH to control allergic reaction.  It sounds a bit scary but gaining a year on the process is appealing.

I'm not sure what I'll do at this point.  I need to mull it over, though I am leaning toward option #2.

Read my other posts about Allergen Immunotherapy here.


If you've had shot treatment for allergies, please take my poll!