SCIT Start

Introduction

Dear Dr. [Receiving Doctor's Last Name], I had the pleasure of seeing [Patient First and Last Name] on [Date of Appointment] for initiation of subcutaneous immunotherapy.

Allergic Rhinitis

[Provide a detailed narrative of the patient's history with allergic rhinitis, including specific allergens. Describe symptoms such as bilateral nasal congestion, rhinorrhea, and sneezing fits. Include the purpose of the visit, such as initiation of subcutaneous immunotherapy for definitive management.]

PAST MEDICAL HISTORY

[List the patient's past medical history and number them.] For example: 1. [Condition 1] 2. [Condition 2]

MEDICATIONS

[List any current medications the patient is taking or indicate if none. Number the medications.]

Allergies

[List the medication allergies and number them.]

INTERVENTIONS

[Insert the following text: Risks and benefits of therapy were discussed and written informed consent was obtained. [Patient's First Name] received: 0.1 mL, Vial #1, R/L Arm They were observed for 30 minutes. A local reaction was observed. No systemic symptoms were observed.]

PHYSICAL EXAMINATION

BP: [insert BP], HR: [Insert HR] BPM [Insert the following text without editing it: [insert patient's name] appears well. Head and neck examination was normal. Cardiac exam revealed a normal S1 and S2. Chest examination is clear with no wheezes or crackles. Skin examination did not reveal active eczema patches or urticaria lesions. The rest of the examination is unremarkable.

IMPRESSION AND PLAN

[Insert the following text: Allergic rhinitis. [Patient's First Name] has tolerated [his/her/their] initial injection well. [He/she] will require approximately 25 weekly visits to reach maintenance dosing (Vial #4 0.5 mL). Once on maintenance dosing, injections can be given every 4-6 weeks for a total of 4-5 years. Local side effects, such as swelling, are common; these are not a contraindication to dose advancement. If bothersome, a non-sedating antihistamine can be taken 1-2 hours prior to the injection. Systemic reactions, including anaphylaxis, occur ~ 1/2000 injections. Fatality is exceedingly rare, ~1/2-8 million injections. Safety steps to minimize reaction risk are below. Injections can be given at any physician’s office capable of treating anaphylaxis. Patent prefers to complete treatment in allergist's/family physician's office. I have recommended a conservative buildup schedule, and listed important safety information below. Safety steps: 1. Patient to double check that the vial/box has their name on it prior to administration 2. Patient to double check the dose (what volume) with nurse/physician based on the immunotherapy dosing prescription 3. Patient to confirm the dose is administered subcutaneously (we use the triceps skin fold for this), and ensure it is not given intra-muscularly. 4. Patient is aware they must wait in the MD’s office for 30-45 minutes after administration of the immunotherapy. Contraindications to immunotherapy: Patients should not receive their immunotherapy as scheduled, and should have it delayed if: 1. They are recently unwell with a cough, cold, fever or gastrointestinal illness 2. Their asthma is poorly controlled 3. There has been a recent worsening of their asthma, requiring extra doses of bronchodilator over the last 5 days. 4. The patient has recently been started on a beta blocker or ACE inhibitor- these medication’s use while on immunotherapy must be reviewed by the allergist before immunotherapy continues. Reasons to phone allergist to adjust dose: 1. Recent episode of anaphylaxis 2. Side effects from immunotherapy that are not tolerated 3. While on maintenance dose: greater than 8 weeks since last dose. Suggested office equipment for immunotherapy: 1. Standards for equipment vary by risk, practice, and distance to hospital. A good resource to consider is : http://www.officeemergencies.ca/ 2. At a minimum, epinephrine for IM administration 0.01mg/kg, max dose of 0.5mg per dose, which can be repeated every 5 minutes must be available in office for emergency use.

FOLLOW UP

[Patient's First Name] will be seen next week for another injection. I would like to see [Patient's First Name] annually for review and to reorder serum. I would appreciate receiving dose administration records to review prior to this time.

Closure

It was a pleasure to see [Patient First and Last Name] today. Thank you again for allowing me to take part in their care.