33.1 The Eternal Question

To treat or not to treat? That is the question every practitioner faces when selecting antigens to place into the patient’s immunotherapy vial. As discussed in Chapter 3, there is a clinical difference between polysensitization and poly-allergy. Do every single allergen that tested positive be treated? Only one or a few antigens are needed—based on the patient’s symptoms or the test results or potency of the antigen or some other criteria? This question is quite controversial and how it is answered can be influenced by geographic location, current knowledge, and provider attitudes/confidence/beliefs. Whether this question is consciously addressed or not by the clinician, it’s one that must be reconciled each and every time a vial prescription is created.

33.2 Treating the Monosensitized/Monoallergic and the Paucisensitized/Pauciallergic Patient

Treating these types of patients, at first glance, seems simple. Some would argue treating this type of patient is easy because this type of patient doesn’t exist. That’s not actually true. While the prevalence of mono/paucisensitization versus polysensitization patients varies geographically, mono/paucisensitized patients are present everywhere in the world. These patients may be less likely to seek treatment because the allergens they are allergic to are avoidable or controlled well with medication. Regardless, physician may encounter patients who fall into this category and there are some treatment questions that need to be reconciled.

Do they have enough “allergies” to “need” treatment? The author’s allergy nurses ask this question or some variant of it from time to time after testing a patient—“Is that patient allergic ‘enough’ to get shots? Are they positive to ‘enough’ allergens?” When creating a treatment plan, this is the wrong question to ask. Patient treatment should be individualized and the decision as to whether or not to treat should be based on patient symptomology, lack of symptom control by medication(s), and/or patient’s desire for treatment, not just test results. It should never be based solely on a number—whether that number is the number of positive test results, the size of a skin wheal, or some other arbitrary number.

Can’t these patients be treated with medication? Of course. Any patient can be treated, including polysensitized patients, with medication alone. The more important questions to answer are “Is this medication(s) controlling that patient’s symptoms without significant side effects,” and “Is this how the patient desires to be treated?”

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