Ailanthus Altissima Pollen

The dosage for Ailanthus Altissima Pollen is highly individualized and must be determined by an allergist based on the patient's level of sensitivity (determined by skin test reactivity) and their clinical history. There is no 'one-size-fits-all' dose.

Diagnostic Testing Dosage

• Skin Prick Test: Typically uses a 1:10 or 1:20 w/v glycerinated extract. A single drop is applied to the skin, and the skin is pricked through the drop.
• Intradermal Test: If the prick test is negative but suspicion remains high, a more dilute aqueous extract (e.g., 1:1000 or 1:500 w/v) is injected into the dermis to form a 2-3 mm wheal.

Immunotherapy (Therapeutic) Dosage

Immunotherapy is divided into two phases:

1. 1Build-up Phase: Starts with a very low dose, often 0.05 mL of a 1:10,000 or 1:1,000 w/v dilution. Injections are given 1 to 3 times per week. The dose is gradually increased (e.g., 0.1 mL, 0.2 mL, 0.3 mL, 0.5 mL) until the maintenance concentration is reached.
2. 2Maintenance Phase: Once the maximum tolerated dose is reached (the 'maintenance dose'), the interval between injections is increased to every 2 to 4 weeks. A common maintenance dose is 0.5 mL of a 1:10 or 1:20 w/v extract, though this varies significantly by patient tolerance.

Ailanthus Altissima Pollen is generally considered safe for use in children, typically starting at age 5. Dosing follows the same 'build-up' and 'maintenance' logic as adult dosing, though initial doses may be even more conservative in highly sensitive children. Children under age 5 may be difficult to treat due to the requirement for frequent injections and the difficulty in communicating early symptoms of a systemic reaction.

Renal Impairment

No dosage adjustments are required for patients with renal impairment, as the proteins are not cleared by the kidneys in an active form.

Hepatic Impairment

No dosage adjustments are required for patients with hepatic impairment.

Elderly Patients

Caution is advised in elderly patients, primarily because they are more likely to have co-morbidities (like cardiovascular disease) that could make the management of a systemic reaction (anaphylaxis) more difficult. Dosing should be cautious, and the use of beta-blockers must be assessed.

• Administration: This medication is administered ONLY by subcutaneous injection (just under the skin), usually in the posterior aspect of the upper arm. It must NEVER be injected intravenously.
• Observation: Patients MUST remain in the medical office for at least 30 minutes after every injection. Most fatal reactions occur within this window.
• Site Care: Do not rub or massage the injection site after the shot, as this can increase the rate of absorption and the risk of a local reaction.
• Storage: Vials must be stored in a refrigerator at 2°C to 8°C (36°F to 46°F). Do not freeze. If the extract becomes cloudy or changes color, it should be discarded.

If a dose is missed during the build-up phase, the next dose may need to be reduced depending on how much time has passed.

• 1-2 weeks late: Repeat the last dose.
• 3-4 weeks late: Reduce the dose by one or two increments.
• Over 4 weeks late: The build-up may need to be restarted from a much lower concentration.

Always consult your allergist if a dose is missed; never attempt to 'double up' to catch up.

An 'overdose' in the context of immunotherapy usually refers to an injection given at a higher concentration than the patient's current tolerance level. Signs of an overdose are identical to a severe systemic allergic reaction:

• Hives (urticaria) or generalized itching.
• Swelling of the throat or tongue.
• Wheezing or difficulty breathing.
• Rapid drop in blood pressure (fainting or dizziness).
• Rapid heart rate.

Emergency Measures: If an overdose/systemic reaction occurs, the immediate treatment is Epinephrine (1:1000) administered intramuscularly. The patient may also require oxygen, intravenous fluids, and antihistamines.

> Important: Follow your healthcare provider's dosing instructions. Do not adjust your dose without medical guidance.

Most patients undergoing immunotherapy with Ailanthus Altissima Pollen will experience local reactions at the site of the injection. These are generally considered a normal part of the body's response to the allergen.

• Local Redness (Erythema): The area around the injection site may turn red and feel warm. This usually appears within minutes and resolves within a few hours.
• Local Swelling (Wheal): A small bump or swelling at the site. If the swelling is smaller than the size of a half-dollar (approx. 3 cm), it is usually not a cause for clinical concern.
• Itching (Pruritus): Localized itching at the injection site is very common and can be managed with topical hydrocortisone or oral antihistamines.

• Large Local Reactions: Swelling that exceeds 5-10 cm in diameter. While not dangerous, these often indicate that the next dose should not be increased or should be reduced.
• Fatigue: Some patients report feeling unusually tired for several hours following their injection.
• Mild Nasal Congestion: A slight 'flare' of hay fever symptoms shortly after the injection.

• Generalized Hives: Itching and welts appearing on parts of the body far from the injection site.
• Angioedema: Swelling of the deeper layers of the skin, often around the eyes or lips.
• Persistent Nodule: A small, hard lump under the skin at the injection site that may last for weeks.

Systemic reactions, including anaphylaxis, are the most serious risks associated with Ailanthus Altissima Pollen. These require immediate intervention.

> Warning: Stop taking Ailanthus Altissima Pollen and call your doctor immediately or seek emergency care if you experience any of these:

• Respiratory Distress: Sudden wheezing, chest tightness, or a feeling that your airway is closing. This indicates bronchospasm or laryngeal edema.
• Hypotension (Shock): A sudden feeling of lightheadedness, fainting, or a rapid, weak pulse. This is a sign of circulatory collapse.
• Cyanosis: A bluish tint to the lips or fingernails, indicating a lack of oxygen.
• Uterine Contractions: In pregnant women, systemic reactions can trigger uterine activity.
• Seizures: Extremely rare, but possible during severe hypoxic (low oxygen) events associated with anaphylaxis.

There is no evidence that long-term use of Ailanthus Altissima Pollen (which typically lasts 3 to 5 years) causes autoimmune diseases or chronic organ damage. The primary 'long-term' effect is the desired one: a permanent or semi-permanent reduction in allergic sensitivity. However, some patients may develop a persistent sensitivity to the injection site itself, manifesting as chronic localized itching.

While Ailanthus Altissima Pollen may not have a specific 'Black Box' for the brand name, the entire class of Allergenic Extracts carries a general warning regarding the risk of severe systemic reactions.

FDA Class Warning Summary: Allergenic extracts can cause severe life-threatening systemic reactions, including anaphylaxis. Patients with unstable or severe asthma are at increased risk. Extracts should only be administered by clinicians trained in the management of anaphylaxis. Patients should be observed for at least 30 minutes post-injection. Epinephrine must be available for immediate use. Patients should be instructed on how to use an epinephrine auto-injector if a delayed reaction occurs.

Report any unusual symptoms to your healthcare provider.

Ailanthus Altissima Pollen is a potent biological substance. Its safety depends entirely on correct administration and patient monitoring. It is not a 'shot' in the traditional sense of a vaccine, but a controlled exposure to an allergen that could, in high enough doses or in sensitive individuals, cause a life-threatening reaction.

No specific FDA black box warnings exist for Ailanthus Altissima Pollen as a standalone product, but it falls under the mandatory class warnings for all allergenic extracts. This warning emphasizes that these products can cause anaphylaxis, and their use is contraindicated in patients with unstable asthma or those taking certain medications like beta-blockers that might complicate the treatment of an allergic reaction.

• Allergic Reactions / Anaphylaxis Risk: The most significant risk is a systemic allergic reaction. This risk is higher if the patient is currently experiencing high levels of environmental exposure to Tree of Heaven pollen, as their 'allergic load' is already high.
• Asthma Stability: Patients with asthma must have their condition well-controlled (e.g., FEV1 > 80% of predicted) before receiving an injection. An injection given during an asthma flare-up can trigger a fatal bronchospasm.
• Injection Technique: Accidental intravenous injection can cause immediate, severe anaphylaxis. The provider must always aspirate (pull back on the syringe) to ensure no blood enters the barrel before injecting.
• Exercise Post-Injection: Patients should avoid vigorous exercise for at least 2 hours after an injection. Exercise increases blood flow and can accelerate the absorption of the allergen into the bloodstream, increasing the risk of a systemic reaction.

• Pre-Injection Assessment: Before every dose, the provider must ask if the patient had a reaction to the previous dose and check for current symptoms of asthma or high fever.
• 30-Minute Wait: This is a non-negotiable safety requirement. Most fatal reactions occur within 20-30 minutes of the injection.
• Peak Flow Monitoring: For asthmatic patients, a peak flow meter may be used to ensure lung function is stable before the injection is administered.

Generally, Ailanthus Altissima Pollen does not affect the ability to drive. However, if a patient experiences a systemic reaction or receives epinephrine, they should not drive until cleared by a medical professional.

There is no direct chemical interaction between alcohol and Ailanthus Altissima Pollen. However, alcohol can cause vasodilation (widening of blood vessels), which may theoretically increase the rate of allergen absorption. It is best to avoid alcohol for several hours after an injection.

Immunotherapy is typically discontinued after 3 to 5 years of successful treatment. There is no 'withdrawal syndrome' associated with stopping allergenic extracts. However, if treatment is stopped prematurely (e.g., after only 1 year), the allergic symptoms are likely to return quickly.

> Important: Discuss all your medical conditions with your healthcare provider before starting Ailanthus Altissima Pollen.

• Beta-Blockers (Non-selective and Selective): This is the most critical interaction. Beta-blockers (e.g., propranolol, metoprolol, atenolol) can make an allergic reaction more severe and, crucially, they can block the effects of epinephrine. If a patient on a beta-blocker has anaphylaxis, the standard dose of epinephrine may not work, leading to a potentially fatal outcome. Many allergists will not perform immunotherapy unless the patient can be safely switched to a different class of blood pressure medication.

• ACE Inhibitors: Some studies suggest that patients taking ACE inhibitors (e.g., lisinopril, enalapril) may be at a higher risk for more severe systemic reactions to immunotherapy, possibly due to the role of the renin-angiotensin system in modulating the inflammatory response.
• MAO Inhibitors (MAOIs) and Tricyclic Antidepressants (TCAs): These medications (e.g., phenelzine, amitriptyline) can potentiate the effects of epinephrine, leading to dangerously high blood pressure or heart rhythm issues if epinephrine must be used to treat a reaction.

• Antihistamines: While often used to manage local reactions, antihistamines can 'mask' the early warning signs of a systemic reaction (like mild itching or sneezing). This might lead a clinician to increase the dose too quickly because they don't see the minor reactions that would normally signal a need for caution.
• Other Immunotherapies: If a patient is receiving multiple types of immunotherapy (e.g., for dust mites or other trees), the injections should be given in different arms, and the doses must be carefully tracked to avoid an additive systemic effect.

There are no known direct food interactions with Ailanthus Altissima Pollen. However, patients with 'Oral Allergy Syndrome' (OAS) may find that certain foods cause itching in the mouth if they share cross-reactive proteins with the pollen. While Tree of Heaven is not commonly associated with major food cross-reactivities (unlike Birch or Ragweed), patients should report any new food sensitivities to their doctor.

• St. John's Wort: May theoretically affect the immune response, though no clinical data exists regarding its interaction with allergenic extracts.
• Immunostimulants (e.g., Echinacea): These may theoretically interfere with the desensitization goals of immunotherapy, which aims to induce tolerance rather than general immune stimulation.

• Skin Testing: Ailanthus Altissima Pollen is itself used for a diagnostic test. Taking antihistamines (like loratadine or cetirizine) will cause a false-negative result on the skin test. These must be stopped for 3-7 days before testing.
• Total IgE and Specific IgE (ImmunoCAP): Immunotherapy will eventually cause changes in these levels (often an initial rise in specific IgE followed by a long-term decline), which should be interpreted by an allergist.

> Important: Tell your doctor about ALL medications, supplements, and herbal products you are taking.

• Severe, Uncontrolled Asthma: Patients whose asthma is not stable are at the highest risk for fatal reactions. If the lungs are already inflamed, the addition of a systemic allergen can cause an irreversible 'shut down' of the airways.
• Recent Myocardial Infarction (Heart Attack): The stress of a potential systemic reaction and the subsequent need for epinephrine (which puts significant strain on the heart) makes immunotherapy too risky for patients with recent or unstable cardiovascular disease.
• Previous Severe Reaction to Immunotherapy: If a patient has had a life-threatening reaction to Ailanthus Altissima Pollen in the past, the risks of continuing usually outweigh the benefits.
• Beta-Blocker Use: As noted in the interactions section, the inability of epinephrine to work effectively in these patients makes immunotherapy an absolute contraindication in many clinical guidelines.

• Pregnancy: While immunotherapy is generally not started during pregnancy due to the risk of a systemic reaction harming the fetus, it is often continued at the maintenance dose if the patient was already tolerating it well before becoming pregnant.
• Autoimmune Disorders: Patients with active, severe autoimmune diseases (like SLE or Rheumatoid Arthritis) may have unpredictable immune responses to allergenic extracts.
• Malignancy: Patients undergoing active chemotherapy or with certain cancers may have compromised immune systems that make immunotherapy less effective or more risky.
• Children under age 5: Due to the inability of very young children to communicate the subtle early symptoms of a systemic reaction (e.g., an 'itchy throat' or 'sense of doom').

Patients allergic to Ailanthus Altissima may show cross-reactivity with other members of the Simaroubaceae family, though this family has few other common aeroallergens in temperate regions. There is limited evidence of significant cross-reactivity with common trees like Oak or Maple, meaning Ailanthus allergy is often distinct and requires its own specific extract for treatment.

> Important: Your healthcare provider will evaluate your complete medical history before prescribing Ailanthus Altissima Pollen.

• FDA Pregnancy Category: Not formally assigned by the FDA for most allergenic extracts, but generally treated as Category C.
• Risk Summary: The primary risk during pregnancy is not the extract itself, but the risk of a systemic reaction (anaphylaxis) in the mother. Anaphylaxis can cause maternal hypotension, leading to placental hypoperfusion (reduced blood flow to the baby) and fetal distress or death.
• Clinical Practice: Guidelines from the American Academy of Allergy, Asthma & Immunology (AAAAI) suggest that immunotherapy should not be initiated during pregnancy. However, if a woman is already on a maintenance dose and is tolerating it well, the treatment can be continued as the risk of a reaction is low.

• Passage into Milk: It is highly unlikely that the allergenic proteins in the extract pass into breast milk in any significant or active form.
• Safety: Immunotherapy is considered safe for breastfeeding mothers. There are no known adverse effects on the nursing infant. The benefits of controlling the mother's allergic asthma or rhinitis often outweigh any theoretical risks.

• Approved Age: Generally safe for children 5 years of age and older.
• Considerations: Pediatric patients often have a higher 'allergic load' and may be more prone to local reactions. Long-term studies suggest that starting immunotherapy in childhood can actually prevent the development of new sensitivities (the 'allergic march') and reduce the risk of developing asthma later in life.

• Cardiovascular Risk: The main concern in patients over 65 is the presence of underlying heart disease. If an older patient requires epinephrine for a reaction, they are at higher risk for arrhythmias or myocardial ischemia.
• Renal/Hepatic: No specific concerns regarding organ clearance, but polypharmacy (taking many medications) increases the risk of drug interactions (e.g., with beta-blockers or ACE inhibitors).

• Dosing: No adjustments needed. The proteins are metabolized by proteases and do not rely on renal excretion.
• Dialysis: These large proteins are not expected to be dialyzable.

• Dosing: No adjustments needed. Hepatic function does not significantly impact the processing of subcutaneous allergenic proteins.

> Important: Special populations require individualized medical assessment.

Ailanthus Altissima Pollen extract induces immunological tolerance through several pathways. Initially, it causes a 'desensitization' of mast cells and basophils, making them less likely to release histamine. Over the long term, it induces the production of T-regulatory (Treg) cells. These cells produce Interleukin-10 (IL-10), which signals B-cells to stop producing IgE and start producing IgG4. IgG4 acts as a 'blocking antibody,' neutralizing the Tree of Heaven pollen before it can reach the IgE on the mast cells.

• Onset of Effect: Clinical improvement is rarely immediate. Most patients begin to notice a reduction in symptoms after reaching the maintenance dose, which usually takes 3 to 6 months.
• Duration of Effect: The goal is a long-lasting modification of the immune system. Studies on other tree pollens suggest that after 3-5 years of treatment, the benefits can last for several years after the injections are stopped.
• Tolerance: Unlike many drugs where 'tolerance' means the drug stops working, in immunotherapy, 'tolerance' is the goal—the body learns to tolerate the allergen without reacting.

| Parameter | Value |

|---|---|

| Bioavailability | N/A (Subcutaneous injection) |

| Protein Binding | N/A (Large proteins) |

| Half-life | Varies (Local depot effect) |

| Tmax | 1-2 hours (for systemic absorption) |

| Metabolism | Proteolysis (Proteases) |

| Excretion | Cellular metabolism |

• Composition: A complex mixture of proteins, glycoproteins, and polysaccharides extracted from the pollen of Ailanthus altissima.
• Potency Measurement: Expressed in PNU (Protein Nitrogen Units), where 1 unit equals 0.01 micrograms of phosphotungstic acid-precipitable nitrogen.
• Solubility: Soluble in aqueous buffers; often provided in a 50% glycerin solution for stability.

Ailanthus Altissima Pollen is a member of the Non-Standardized Pollen Allergenic Extract class. It is grouped with other tree pollen extracts like Oak, Hickory, and Elm, though each is specific to its own species-specific allergens.