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English Walnut Dailymed

  1. Non-standardized Allergenic Label
  2. Non-Standardized Food Allergenic Extract
  3. Greer Laboratories, Inc.

Generic: juglans regia

English Walnut solution - image

Boxed Warning

Full Prescribing Information

WARNING: SEVERE ALLERGIC REACTIONS
  • Non-Standardized Allergenic Extracts can cause severe life-threatening systemic reactions, including anaphylaxis. (5.1)
  • Do not administer these products to patients with severe, unstable or uncontrolled asthma. (4)
  • Observe patients in the office for at least 30 minutes following treatment. Emergency measures and personnel trained in their use must be available immediately in the event of a life-threatening reaction. (5.1)
  • Patients with extreme sensitivity to these products, those on an accelerated immunotherapy build-up schedule, those switching to another allergenic lot, those receiving high doses of Non-Standardized Allergenic Extracts, or those also exposed to similar allergens may be at increased risk of a severe allergic reaction. (5.1)
  • These products may not be suitable for patients with certain underlying medical conditions that may reduce their ability to survive a serious allergic reaction. (5.1)
  • These products may not be suitable for patients who may be unresponsive to epinephrine or inhaled bronchodilators, such as those taking beta-blockers. (5.2)

  1. FDA Adverse Reactions

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Recent Major Change


Warning and Precautions, Anaphylaxis Following False Negative Food Allergen Skin Test Results (5.3) 01/2023

Highlights Of Prescribing Information


These highlights do not include all the information needed to use Non-Standardized Allergenic Extracts (Pollens, Molds, Epidermals, Insects, Foods and Miscellaneous Inhalants) safely and effectively. See full prescribing information for Non-Standardized Allergenic Extracts.

Non-Standardized Allergenic Extracts (Pollens, Molds, Epidermals, Insects, Foods, and Miscellaneous Inhalants)

Solutions for percutaneous, intradermal or subcutaneous administration.

Initial U.S. Approval: 1968

WARNING: SEVERE ALLERGIC REACTIONS

See full prescribing information for complete boxed warning.
  • Non-Standardized Allergenic Extracts can cause severe life-threatening systemic reactions, including anaphylaxis. (5.1)
  • Do not administer these products to patients with severe, unstable or uncontrolled asthma. (4)
  • Observe patients in the office for at least 30 minutes following treatment.Emergency measures and personnel trained in their use must be available immediately in the event of a life-threatening reaction. (5.1)
  • Patients with extreme sensitivity to these products, on an accelerated immunotherapy build-up, switching to another lot, receiving high doses of these products, and patients exposed to similar allergens may be at increased risk of a severe allergic reaction. (5.1)
  • These products may not be suitable for patients with certain underlying medical conditions that may reduce their ability to survive a systemic allergic reaction, and for patients receiving medications such as beta-blockers that may make them unresponsive to epinephrine or inhaled bronchodilators. (5.1, 5.2)

RECENT MAJOR CHANGES Warning and Precautions, Anaphylaxis Following False Negative Food Allergen Skin Test Results (5.3) 01/2023

INDICATIONS AND USAGE

Non-Standardized Allergenic Extracts are indicated for:
  • Skin test diagnosis of patients with a clinical history of allergies to one or more of the specific allergens. (1)
  • Immunotherapy for reduction of allergen-induced allergic symptoms confirmed by appropriate positive skin tests or in vitro testing for allergen-specific IgE antibodies. (1)

Food extracts have not been proven safe or effective in allergen immunotherapy.

DOSAGE AND ADMINISTRATION

For percutaneous, intradermal or subcutaneous use only.

The extracts are diluted with sterile diluents when used for intradermal testing or subcutaneous immunotherapy. For percutaneous testing, the extracts are diluted with sterile diluents in patients expected to be at greater risk for systemic allergic reaction. Dosages vary by mode of administration and by individual response. See full prescribing information for instructions on preparation, administration, and adjustments of dose. (2.1)

DOSAGE FORMS AND STRENGTHS

Non-Standardized Allergenic Extracts are labeled in weight/volume and/or protein nitrogen units (PNU)/milliliter (a measure of total protein), and are supplied as sterile aqueous stock concentrates at up to 1:10 weight/volume or 40,000 PNU/milliliter, or 50% glycerin stock concentrates at up to 1:20 weight/volume. (3)

CONTRAINDICATIONS
  • Severe, unstable or uncontrolled asthma. (4)
  • History of any severe systemic or local allergic reaction to an allergen extract. (4)

WARNINGS AND PRECAUTIONS

Severe allergic reactions have occurred following the administration of other allergenic extracts and may occur in individuals following the administration of Non-Standardized Allergenic Extracts in the following situations:
  • Extreme sensitivity to Non-Standardized Allergenic Extracts, receipt of high doses of Non-Standardized Allergenic Extracts, or concomitant exposure to similar environmental allergens. (5.1)
  • Receiving an accelerated immunotherapy build-up schedule (e.g., “rush†immunotherapy), or changing from one allergenic lot to another. (5.1)

ADVERSE REACTIONS

The most common adverse reactions, occurring in 26 to 82% of all patients who receive subcutaneous immunotherapy, are local adverse reactions at the injection site (e.g., erythema, itching, swelling, tenderness, pain). (6)

Systemic adverse reactions, occurring in ≤ 7% of patients who receive subcutaneous immunotherapy, include generalized skin erythema, urticaria, pruritus, angioedema, rhinitis, wheezing, laryngeal edema, and hypotension.

These can be fatal. (6)

To report SUSPECTED ADVERSE REACTIONS, contact GREER Laboratories, Inc. at 1-855-274-1322 or FDA at 1-800-FDA-1088 or www.fda.gov/medwatch .

DRUG INTERACTIONS
  • Antihistamines and other medications that suppress histamine, including topical corticosteroids, topical anesthetics and tricyclic antidepressants can interfere with skin test results. (7)

See 17 for PATIENT COUNSELING INFORMATION

Full Prescribing Information: Contents*


WARNING: SEVERE ALLERGIC REACTIONS 1 INDICATIONS AND USAGE 2 DOSAGE AND ADMINISTRATION 2.1 Preparation for Administration 2.2 Diagnostic Testing 2.3 Immunotherapy 3 DOSAGE FORMS AND STRENGTHS 4 CONTRAINDICATIONS 5 WARNINGS AND PRECAUTIONS 5.1 Serious Systemic Adverse Reactions 5.2 Epinephrine 5.3 Anaphylaxis Following False Negative Food Allergen Skin Test Results 5.4 Cross-Reactions and Dose Sensitivity 6 ADVERSE REACTIONS 7 DRUG INTERACTIONS 7.1 Antihistamines 7.2 Topical Corticosteroids and Topical Anesthetics 7.3 Tricyclic Antidepressants 8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Lactation 8.4 Pediatric Use 8.5 Geriatric Use 11 DESCRIPTION 12 CLINICAL PHARMACOLOGY 12.1 Mechanism of Action 14 CLINICAL STUDIES 15 REFERENCES 16 HOW SUPPLIED/STORAGE AND HANDLING 16.1 How Supplied 16.2 Storage and Handling 17 PATIENT COUNSELING INFORMATION *Sections or subsections omitted from the Full Prescribing Information are not uled.

Full Prescribing Information


WARNING: SEVERE ALLERGIC REACTIONS
  • Non-Standardized Allergenic Extracts can cause severe life-threatening systemic reactions, including anaphylaxis. (5.1)
  • Do not administer these products to patients with severe, unstable or uncontrolled asthma. (4)
  • Observe patients in the office for at least 30 minutes following treatment. Emergency measures and personnel trained in their use must be available immediately in the event of a life-threatening reaction. (5.1)
  • Patients with extreme sensitivity to these products, those on an accelerated immunotherapy build-up schedule, those switching to another allergenic lot, those receiving high doses of Non-Standardized Allergenic Extracts, or those also exposed to similar allergens may be at increased risk of a severe allergic reaction. (5.1)
  • These products may not be suitable for patients with certain underlying medical conditions that may reduce their ability to survive a serious allergic reaction. (5.1)
  • These products may not be suitable for patients who may be unresponsive to epinephrine or inhaled bronchodilators, such as those taking beta-blockers. (5.2)

1 Indications And Usage


Non-Standardized Allergenic Extracts are indicated for:
  • Skin test diagnosis of patients with a clinical history of allergies to one or more of the specific non-standardized allergens.
  • Immunotherapy for the reduction of allergen-induced allergic symptoms confirmed by appropriate positive skin tests or by in vitro testing for allergen-specific IgE antibodies.

Food extracts have not been proven safe or effective in allergen immunotherapy.

2 Dosage And Administration


For percutaneous, intradermal or subcutaneous use only.

The extracts are diluted with sterile diluents when used for intradermal testing or subcutaneous immunotherapy. For percutaneous testing, the extracts are diluted with sterile diluents in patients expected to be at greater risk for systemic allergic reaction. Dosages vary by mode of administration and by individual response.

2.1 Preparation for Administration

Parenteral drug products should be inspected visually for particulate matter and discoloration prior to administration, whenever solution and container permit. Discard solution if either of these conditions exist.

The extracts are diluted with sterile diluents when used for percutaneous and intradermal testing, or for subcutaneous immunotherapy.

Extracts labeled “For Diagnostic Use Only†are intended for percutaneous and intradermal testing only. These extracts have not been shown by adequate data to be safe and effective for therapeutic use. The extracts labeled For Diagnostic Use Only are the foods Barley, Coffee, Oat, Pineapple, Rye, Spinach, Wheat, the insects Flea, House Fly, Mosquito, and the plant and plant parts Cottonseed and Flax.

Undiluted 50% glycerin stock concentrate is used for percutaneous testing. To prepare 10-fold dilutions for percutaneous testing in patients suspected to be at greater risk for systemic allergic reaction, start with the stock concentrate. Proceed as shown in Table 1. The 10-fold dilution series uses 0.5 milliliters of concentrate added to 4.5 milliliters of sterile 50% glycerin diluent. Subsequent dilutions are made in a similar manner.

To prepare 10-fold dilutions for intradermal testing and immunotherapy, start with a 1:10 weight/volume, 1:20 weight/volume, or up to a 40,000 PNU/milliliter stock concentrate. Proceed as shown in Table 1. The 10-fold dilution series uses 0.5 milliliter of concentrate added to 4.5 milliliters of sterile diluent (glycerin-free diluents for intradermal testing, glycerin-free or 10% glycerin-saline diluents for immunotherapy). Subsequent dilutions are made in a similar manner.
Table 1: 10-fold Dilition Series*
Dilution Extract Milliliters of Diluent Dilution Strength (w/v) Dilution Strength (w/v) Dilution Strength (PNU/milliliter)
0 Concentrate 1:10 1:20 20,000
1 0.5 mL Concentrate 4.5 1:100 1:200 2,000
2 0.5 mL Dilution 1 4.5 1:1,000 1:2,000 200
3 0.5 mL Dilution 2 4.5 1:10,000 1:20,000 20
4 0.5 mL Dilution 3 4.5 1:100,000 1:200,000 2
5 0.5 mL Dilution 4 4.5 1:1,000,000 1:2,000,000 0.2
6 0.5 mL Dilution 5 4.5 1:10,000,000 1:20,000,000 0.02

*There is no direct potency correlation across the table between PNU/milliliter and w/v.

Undiluted 50% glycerin stock concentrate is used for percutaneous testing. To prepare 5-fold dilutions for percutaneous testing in patients suspected to be at greater risk for systemic allergic reaction, start with the stock concentrate. Proceed as shown in Table 2. The 5-fold dilution series uses 1 milliliter of concentrate added to 4 milliliters of sterile 50% glycerin diluent. Subsequent dilutions are made in a similar manner.

To prepare 5-fold dilutions for intradermal testing or immunotherapy, start with a 1:10 weight/volume, 1:20 weight/volume, or up to a 40,000 PNU/milliliter stock concentrate. Proceed as shown in Table 2. The 5-fold dilution series uses 1 milliliter of concentrate added to 4 milliliters of sterile diluent (glycerin-free diluents for intradermal testing, glycerin-free or 10% glycerin-saline diluents for immunotherapy). Subsequent dilutions are made in a similar manner.
Table 2: 5-fold Dilution Series*
Dilution Extract Milliliters of Diluent Dilution Strength (w/v) Dilution Strength (w/v) Dilution Strength (PNU/milliliter)
0 Concentrate 1:10 1:20 20,000
1 1 mL Concentrate 4 1:50 1:100 4,000
2 1 mL Dilution 1 4 1:250 1:500 800
3 1 mL Dilution 2 4 1:1,250 1:2,500 160
4 1 mL Dilution 3 4 1:6,250 1:12,500 32
5 1 mL Dilution 4 4 1:31,250 1:62,500 6.4
6 1 mL Dilution 5 4 1:156,250 1:312,500 1.28

*There is no direct potency correlation across the table between PNU/milliliter and w/v.

2.2 Diagnostic Testing

Diagnostic testing can be performed via percutaneous or intradermal administration of the Non-Standardized Allergenic Extracts. A positive skin test reaction should be interpreted in relation to the patient’s history and known exposure to the specific allergen(s).

Percutaneous Skin Testing

Preparation and Dose

For percutaneous testing (prick or puncture), use glycerinated extract; use the extracts at the highest available stock concentration. In patients suspected to be at greater risk for systemic allergic reaction, use 10-fold or 5-fold dilutions of the concentrate.

Prick test: Place one drop of extract with appropriate controls on the skin and with a skin test device, pierce through the drop into the skin with a slight lifting motion. Alternatively, use skin test devices loaded with the extract from the storage trays in a similar manner or in accordance with the device manufacturer’s recommendations.

Puncture test: Place one drop of extract or control on the skin and pierce the skin through the drop with a skin test device perpendicular to the skin. Alternatively, use skin test devices loaded with the extract from the storage trays in a similar manner or in accordance with the device manufacturer’s recommendations.

Interpreting Results

When using percutaneous skin test devices, follow the directions provided with the test devices. A glycerinated histamine control solution (6 milligrams/milliliter or 1 milligram/milliliter histamine base) may be used as the positive control. A 50% glycerin-saline solution may be used as the negative control.

Read and record skin test responses 15 to 20 minutes after exposure. Individual patient reactivity can vary with time, allergen potency, and/or immunotherapy, as well as testing technique. The most reliable method of recording a skin test reaction is to measure the largest diameter of both wheal and erythema. While some correlation exists between the size of the skin test reaction and the degree of sensitivity, other factors should be considered in the diagnosis of allergy to specific allergens (see Figure 1 below).

Figure 1: Measurement of Wheal and Flare

Use a paper or plastic millimeter skin reaction guide as shown below.



Fifteen minutes after application of the skin test, measure the length and midpoint orthogonal width of each flare and wheal from the inner edge of the reaction.



The length of the skin test is defined as the largest diameter and the width of the skin test is defined as the diameter perpendicular to the length at its midpoint. Consider the wheal and flare as separate entities. First, measure the flare and then independently measure the wheal.

Measuring the Flare



Measuring the Wheal



The average diameter measurement in the example above of the flare is (26 mm + 36 mm)/2 = 31 mm and the average diameter of the wheal is (10 mm + 16 mm)/2 = 13 mm.

Responses to positive controls should be at least 3 millimeters larger than responses to the negative controls.

Negative controls should elicit no reaction or only reactions of small diameter (less than 2 millimeters wheal, less than 5 millimeters erythema).

If either the positive or negative control response does not meet the above criteria, results for the allergenic extracts tested at the same time should be considered invalid and be repeated.

Intradermal Skin Testing

Preparation and Dose

For intradermal testing, dilute stock concentrate to 1:100 to 1:1000 volume to volume of Non-Standardized Allergenic Extracts stock concentrate solution. Dilute the stock concentrate solution with sterile diluent [see Dosage and Administration (2.1)]. Use normal or buffered saline or normal saline with human serum albumin (HSA) diluent. If the result from the initial test dose is negative, subsequent intradermal tests using increasingly stronger doses may be performed up to the maximum recommended strength of 1:25 volume to volume dilution of the extract concentrate solution.

Inject 0.02 milliliters of the extract solution intradermally according to the algorithms shown in Figure 2.

Figure 2: Algorithm for Dilution of Stock Concentrate Solution of Non-Standardized Allergenic Extracts for Intradermal Skin Testing



1 Corresponds to 1:10,000 - 1:15,625 volume to volume dilution of 1:20 weight/volume glycerinated extract concentrates

2 Corresponds to 1:100 - 1:125 volume to volume dilution of 1:20 weight/volume glycerinated extract concentrates

3 Corresponds to 1:50 - 1:100 volume to volume dilution of 1:20 weight/volume glycerinated extract concentrates

4 Corresponds to 1:25 - 1:100 volume to volume dilution of 1:20 weight/volume glycerinated extract concentrates

2.3 Immunotherapy

For subcutaneous administration only.

Preparation and Dose

Stock concentrates of Non-Standardized Allergenic Extracts are available in aqueous (up to 1:10 weight/volume or 40,000 PNU/milliliter) and 50% glycerin (up to 1:20 weight/volume) strengths for immunotherapy. Stock concentrates are diluted in normal saline, buffered saline, HSA-saline, or 10% glycerin-saline, depending on the patient’s reactivity to the diluent. See Table 1 and Table 2 for dilution preparation.

Administration of Immunotherapy

Administer immunotherapy by subcutaneous injection in the lateral aspect of the upper arm or thigh. Avoid injection directly into any blood vessel.

The optimal interval between doses of allergenic extract varies among individuals. Injections are usually given 1 to 2 times per week until the maintenance dose is reached, at which time the injection interval is increased to 2, then 3, and finally 4 weeks. Dosages vary by mode of administration, and by clinical response and tolerance. The minimum course of treatment may be three to five years, depending on the clinical response.

Guidelines for Immunotherapy

The initial dose of the extract should be based on the skin test reactivity. In patients suspected to be at greater risk for systemic allergic reaction by history and skin test, the initial dose of the extract should be 0.05 milliliter of a 1:20,000,000 to 1:2,000,000 weight/volume extract dilution. Patients not suspected to be at greater risk for systemic allergic reaction may be started at 0.1 milliliter of a 1:200,000 to 1:20,000 weight/volume extract dilution.

The dose of allergenic extract is increased at each injection by no more than 50% of the previous dose, and the next increment is governed by the response to the last injection.

Select the maximum tolerated maintenance dose based on the patient’s clinical response and tolerance. Doses larger than 0.2 milliliter of the stock concentrate are rarely administered because an extract in 50% glycerin diluent can cause discomfort upon injection.

Dosage Modification Guidelines for Immunotherapy

The following conditions may indicate a need to withhold or reduce the dosage of immunotherapy.
  • Symptoms of rhinitis and/or asthma
  • Infection accompanied by fever
  • Exposure to excessive amounts of clinically relevant environmental allergen prior to a scheduled injection
  • Large local reactions that persist for longer than 24 hours can be an indication for repeating the previous dose or reducing the dose at the next administration

Any evidence of a systemic reaction is an indication for a significant reduction (at least 75%) in the subsequent dose. Repeated systemic adverse reactions are sufficient reason for the cessation of further attempts to increase the dose.

Local adverse reactions require a decrease in the next dose by at least 50%. Proceed cautiously in subsequent dosing. In situations prompting dose reduction, once the reduced dose is tolerated, a cautious increase in dosage can be attempted.

Changing extract to a different lot or from a different manufacturer: When switching to a different lot of extract, or from another manufacturer’s extract, decrease the starting dose. Because manufacturing processes and sources of raw materials differ among manufacturers, the interchangeability of extracts from different manufacturers cannot be assured. In general, a dose reduction of 50 to 75% of the previous dose should be adequate, but each situation must be evaluated separately, considering the patient’s history of sensitivity, tolerance of previous injections, and other factors. Dose intervals should not exceed one week when rebuilding the dose.

Unscheduled gaps between treatments: Patients can lose tolerance to allergen injections during prolonged periods between doses, which increases their risk for an adverse reaction. The duration of tolerance between injections varies from patient to patient.

During the build-up phase, when patients receive injections 1 to 2 times per week, repeat or reduce the extract dosage if there

has been a substantial time interval between injections. This depends on: 1) the concentration of allergen immunotherapy extract that is to be administered; 2) a previous history of systemic reactions; and 3) the degree of variation from the prescribed interval of time, with longer intervals since the last injection leading to greater reductions in the dose to be administered.

This suggested approach to dose modification, due to unscheduled gaps between treatments during the build-up phase, is not based on published evidence. The individual physician should use this or a similar protocol for the specific clinical setting.

Similarly, if unscheduled gaps occur during maintenance therapy, it may be necessary to reduce the dosage and bring the patient up to maintenance dosing using an established build-up protocol.

Changing from non-stabilized to human serum albumin (HSA) stabilized diluents: Allergenic extracts prepared with diluents containing HSA and 0.4% phenol are more stable than those prepared with diluents that do not contain stabilizers. When switching from a non-stabilized to an HSA-stabilized diluent, consider lowering the dose for immunotherapy.

3 Dosage Forms And Strengths


Non-Standardized Allergenic Extracts are labeled in weight/volume and/or protein nitrogen units (PNU)/milliliter (a measure of total protein), and are supplied as sterile aqueous stock concentrates at up to 1:10 weight/volume or 40,000 PNU/milliliter, or 50% glycerin stock concentrates at up to 1:20 weight/volume.

4 Contraindications


Non-Standardized Allergenic Extracts are contraindicated in patients with:
  • Severe, unstable or uncontrolled asthma
  • History of any severe systemic or local allergic reaction to an allergen extract

5 Warnings And Precautions


5.1 Serious Systemic Adverse Reactions

Serious systemic adverse reactions have occurred following the administration of other allergenic extracts and may occur in individuals following the administration of Non-Standardized Allergenic Extracts in the following situations:
  • Extreme sensitivity to the specific allergen(s)
  • Receipt of an accelerated immunotherapy build-up schedule (e.g., “rush†immunotherapy)
  • Receipt of high doses of allergenic extracts or concomitant exposure to similar environmental allergens
  • Change from one allergenic extract lot to another allergenic extract lot

High-risk patients have had fatal reactions. Consider using more dilute preparations in patients suspected to be at greater risk of systemic allergic reaction [see Dosage and Administration (2.1)].

Administer Non-Standardized Allergenic Extracts in a healthcare setting under the supervision of a physician prepared to manage a severe systemic or a severe local allergic reaction.Observe patients in the office for at least 30 minutes following administration. 1

5.2 Epinephrine

Non-Standardized Allergenic Extracts may not be suitable for patients with certain medical conditions that may reduce the ability to survive a serious allergic reaction or increase the risk of adverse reactions after epinephrine administration. Examples of these medical conditions include but are not limited to: markedly compromised lung function (either chronic or acute), unstable angina, recent myocardial infarction, significant arrhythmia, and uncontrolled hypertension.

These products may not be suitable for patients who are taking medications that can potentiate or inhibit the effect of epinephrine. These medications include:

Î’eta-adrenergic blockers: Patients taking beta-adrenergic blockers may be unresponsive to the usual doses of epinephrine used to treat serious systemic reactions, including anaphylaxis. Specifically, beta-adrenergic blockers antagonize the cardiostimulating and bronchodilating effects of epinephrine.

Alpha-adrenergic blockers, ergot alkaloids: Patients taking alpha-adrenergic blockers may be unresponsive to the usual doses of epinephrine used to treat serious systemic reactions, including anaphylaxis. Specifically, alpha-adrenergic blockers antagonize the vasoconstricting and hypertensive effects of epinephrine. Similarly, ergot alkaloids may reverse the pressor effects of epinephrine.

Tricyclic antidepressants, levothyroxine sodium, monoamine oxidase inhibitors, and certain antihistamines: The adverse effects of epinephrine may be potentiated in patients taking tricyclic antidepressants, levothyroxine sodium, monoamine oxidase inhibitors, and the antihistamines chlorpheniramine, and diphenhydramine.

Cardiac glycosides, diuretics: Patients who receive epinephrine while taking cardiac glycosides or diuretics should be observed carefully for the development of cardiac arrhythmias.

5.3 Anaphylaxis Following False Negative Food Allergen Skin Test Results False negative skin test results associated with anaphylaxis from subsequent exposure to the allergen have been reported during postmarketing diagnostic use of some food allergenic extracts. Based on the patient’s clinical history and index of suspicion, healthcare providers should consider confirming negative skin testing with serologic testing by measuring specific serum IgE or with a medically-supervised oral food challenge.

5.4 Cross-Reactions and Dose Sensitivity

When determining the final dose of an allergen mixture for immunotherapy, consider cross-reactivity among component extracts.

Determine the initial dilution of allergenic extract, starting dose, and progression of dosage based on the patient’s history and results of skin tests 2 [see Dosage and Administration (2.1)]. Strongly positive skin tests can be indicators for potential adverse reactions.

6 Adverse Reactions


The most common adverse reactions, occurring in 26 to 82% of all patients who receive subcutaneous immunotherapy are local adverse reactions at the injection site (e.g., erythema, itching, swelling, tenderness, pain). 1 Systemic adverse reactions, occurring in ≤ 7% of patients who receive subcutaneous immunotherapy, 3 include generalized skin erythema, urticaria, pruritus, angioedema, rhinitis, wheezing, laryngeal edema, and hypotension. These adverse reactions can be fatal. 1

The allergenic extracts labeled “For Diagnostic Use Only†that contain sodium formaldehyde sulfoxylate (SFS) can cause slight discoloration of the skin at the site of administration. This discoloration can remain for extended amounts of time.

7 Drug Interactions


7.1 Antihistamines

Do not perform skin testing with allergenic extracts within 3 to 10 days of use of first-generation H1-histamine receptor blockers (e.g., clemastine, diphenhydramine) and second-generation antihistamines (e.g., loratadine, cetirizine). These products suppress histamine skin test reactions and could mask a positive response. 2

7.2 Topical Corticosteroids and Topical Anesthetics

Topical corticosteroids can suppress skin reactivity; therefore, discontinue use at the skin test site for 2 to 3 weeks before skin testing. Avoid use of topical local anesthetics at skin test sites as they can suppress flare responses. 2

7.3 Tricyclic Antidepressants

Tricyclic antidepressants can have potent antihistamine effects that can affect skin testing. If tricyclic medication has been recently discontinued, allow 7 to 14 days before initiating skin testing. 2

8 Use In Specific Populations


8.1 Pregnancy

Risk Summary

All pregnancies have a risk of birth defect, loss, or other adverse outcomes. In the U.S. general population, the estimated background risk of major birth defects and miscarriage in clinically recognized pregnancies is 2 to 4% and 15 to 20%, respectively. There are no human or animal data to establish the presence or absence of Non-Standardized Allergenic Extracts-associated risks during pregnancy.

8.2 Lactation

Risk Summary

It is not known whether Non-Standardized Allergenic Extracts are present in human milk. Data are not available to assess the effects of these extracts on the breastfed child or on milk production/excretion. The developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for Non-Standardized Allergenic Extracts and any potential adverse effects on the breastfed child from the extracts or from the underlying maternal condition.

8.4 Pediatric Use

For use of these products in children younger than 5 years of age, consideration should be given to the patient’s ability to comply and cooperate with allergen immunotherapy and the potential for difficulty in communicating with the child regarding systemic reactions. 1

8.5 Geriatric Use

Data are not available to determine if subjects 65 years of age and older respond differently to allergen immunotherapy than younger subjects.

11 Description


Non-Standardized Allergenic Extracts are sterile solutions used for percutaneous testing, intradermal testing, or subcutaneous immunotherapy. Aqueous extracts contain the soluble extractants of the source material in water for injection, 0.5% sodium chloride, 0.54% sodium bicarbonate, and 0.4% phenol. Glycerinated extracts contain the soluable extractants of the source material in water for injection and 50% glycerin, 0.25% sodium chloride, 0.27% sodium bicarbonate, and 0.2% phenol. The pH of the extracts range from 6 to 9.

Certain food extracts (Barley, Oat, Pineapple, Rye, Spinach, and Wheat), labeled “For Diagnostic Use Onlyâ€, contain 0.1% sodium formaldehyde sulfoxylate as an antioxidant.

Source materials used in the manufacture of allergenic extracts are collected from natural sources or from laboratory cultures.

Non-Standardized Allergenic Extracts appear as clear and colorless to dark brown solutions that should be free of particulate matter.

Extracts are labeled either as weight-to-volume based on the weight of the source material to the volume of the extracting fluid, or as PNU/milliliter with one PNU representing 0.00001 mg of protein nitrogen per milliliter.

12 Clinical Pharmacology


12.1 Mechanism of Action

The skin test reaction results from interaction of the introduced allergen and allergen-specific IgE antibodies bound to mast cells, leading to mast cell degranulation and release of histamine, tryptase and other mediators, which results in the formation of the wheal and flare.

The precise mechanisms of action of allergen immunotherapy are not known. Immunologic responses to immunotherapy include changes in allergen-specific IgE levels, allergen-specific IgG levels, and regulatory T cell responses. 1

14 Clinical Studies


Specific immunotherapy with allergenic extracts is helpful in reducing symptoms associated with exposure to the offending allergens. A summary of effectiveness by the Panel on Review of Allergenic Extracts, an advisory committee to the U.S. Food and Drug Administration, has been published. 4

15 References

  • Cox LJ, Nelson H, Lockey R.Allergen immunotherapy: A practice parameter third update. J Allergy Clin Immunol. 2011;127:(1)S1-55.
  • Bernstein IL, Li JT, Bernstein DI, et al.Allergy diagnostic testing: an updated practice parameter. Ann Allergy Asthma Immunol. 2008;100:S1-148.
  • Greenberg MA, Kaufman CR, Gonzalez GE, et al. Late and immediate systemic-allergic reactions to inhalant allergen immunotherapy. J Allergy Clin Immunol. 1986;77:865-870.
  • Federal Register Proposed Rule: Biological Products: Implementation of Efficacy Review, Allergenic Extracts, Federal Register 1985;50: 3082-3288.

16 How Supplied/storage And Handling


16.1 How Supplied

Non-Standardized Allergenic Extracts and mixes may be supplied as aqueous stock concentrates of up to 1:10 weight/volume or 40,000 PNU/milliliter for intradermal and subcutaneous testing. The extracts may also be supplied as 50% glycerin stock concentrates of up to 1:20 weight/volume for use in percutaneous skin testing and subcutaneous immunotherapy. Non-Standardized Allergenic Extracts are labeled in weight/volume and/or PNU/milliliter and may be provided in 5, 10, and 50 milliliter vials. Glycerinated extracts are also supplied in 5 milliliter dropper vials for prick or puncture testing.

Non-Standardized Allergenic Extracts available are as follows:
Pollens ‑ Grasses
Bahia Grass, Paspalum notatum
Brome, Smooth, Bromus inermis
Canarygrass, Reed, Phalaris arundinacea
Johnson Grass, Sorghum halepense
Quack (Couch) Grass, Elymus repens
Ryegrass, Giant Wild, Leymus condensatus
Velvetgrass, Holcus lanatus
Wheatgrass, Western, Pascopyrum smithii
Pollens - Trees
Acacia, Acacia dealbata
Alder, Hazel, Alnus serrulata
Alder, Red, Alnus rubra
Alder, White, Alnus rhombifolia
Ash, Arizona (Velvet), Fraxinus velutina
Ash, Green, Fraxinus pennsylvanica
Ash Mix (Equal parts Fraxinus pennsylvanica, Fraxinus americana)
Ash, Oregon, Fraxinus latifolia
Ash, White, Fraxinus americana
Aspen, Populus tremuloides
Beech, American, Fagus grandifolia
Birch, Black-Sweet, Betula lenta
Birch, Mix (Equal parts Betula lenta, Betula nigra, Betula populifolia)
Birch, River, Betula nigra
Birch, Spring, Betula occidentalis
Birch, White, Betula populifolia
Box Elder, Acer negundo
Cedar, Mountain, Juniperus ashei
Cedar, Red, Juniperus virginiana
Cedar, Salt (Tamarisk), Tamarix gallica
Central/Eastern 4 Tree Mix (Equal parts Ulmus americana, Acer negundo, Carya illinoinensis, Quercus virginiana)
Cottonwood, Arizona (Fremont), Populus fremontii
Cottonwood, Black, Populus trichocarpa
Cottonwood, Eastern, Populus deltoides
Cottonwood, Western, Populus deltoides ssp. monilifera
Cypress, Arizona, Callitropsis arizonica
Cypress, Bald, Taxodium distichum
Eastern Oak Mix (Equal parts Quercus velutina, Quercus rubra, Quercus alba)
Eastern 6 Tree Mix (Equal parts Fagus grandifolia, Populus deltoides, Quercus rubra, Betula nigra, Carya ovata, Fraxinus americana)
Eastern 7 Tree Mix (Equal parts Ulmus americana, Fagus grandifolia, Populus deltoides, Quercus rubra, Betula nigra, Carya ovata, Fraxinus americana)
Eastern 8 Tree Mix (Equal parts Ulmus americana, Fagus grandifolia, Populus deltoides, Quercus rubra, Betula nigra, Carya ovata, Fraxinus americana, Acer saccharum)
Eastern 10 Tree Mix (Equal parts Platanus occidentalis, Ulmus americana, Fagus grandifolia, Populus deltoides, Quercus rubra, Betula nigra, Carya ovata, Fraxinus americana, Acer saccharum, Liquidambar styraciflua)
Elm, American, Ulmus americana
Elm, Cedar, Ulmus crassifolia
Elm Mix (Equal parts Ulmus americana, Ulmus pumila)
Elm, Siberian, Ulmus pumila
Eucalyptus, Bluegum, Eucalyptus globulus
Hackberry, Celtis occidentalis
Hazelnut, American, Corylus americana
Hickory Mix (Equal parts Carya glabra, Carya ovata, Carya laciniosa, Carya tomentosa)
Hickory-Pecan Mix (Equal parts Carya illinoinensis, Carya ovata)
Hickory, Shagbark, Carya ovata
Hickory, Shellbark, Carya laciniosa
Hickory, White, Carya tomentosa
Juniper Mix (Equal parts Juniperus monosperma, Juniperus scopulorum)
Juniper, Oneseed, Juniperus monosperma
Juniper, Pinchot, Juniperus pinchotii
Juniper, Rocky Mountain, Juniperus scopulorum
Juniper, Utah, Juniperus osteosperma
Juniper, Western, Juniperus occidentalis
Locust Blossom, Black, Robinia pseudoacacia
Mango Blossom, Mangifera indica
Maple-Box Elder Mix (Equal parts Acer saccharum, Acer negundo)
2 Maple Mix (Equal parts Acer rubrum, Acer saccharum)
3 Maple Mix (Equal parts Acer rubrum, Acer saccharinum, Acer saccharum)
Maple, Red, Acer rubrum
Maple, Silver/Soft, Acer saccharinum
Maple, Sugar/Hard, Acer saccharum
Melaleuca, Melaleuca quinquenervia
Mesquite, Velvet Prosopis velutina
Mulberry, Paper, Broussonetia papyrifera
Mulberry, Red, Morus rubra
Mulberry, White, Morus alba
Oak, Arizona (Gambel), Quercus gambelii
Oak, Black, Quercus velutina
Oak, Bur, Quercus macrocarpa
Oak, California Black, Quercus kelloggii
Oak, California Live, Quercus agrifolia
Oak, California White, Quercus lobata
Oak, Post, Quercus stellata
Oak, Red, Quercus rubra
Oak, Virginia Live, Quercus virginiana
Oak, Water, Quercus nigra
Oak, Western White, Quercus garryana
Oak, White, Quercus alba
Olive, Olea europaea
Olive, Russian, Elaeagnus angustifolia
Orange Pollen, Citrus X sinensis
Palm, Queen, Syagrus romanzoffiana
Pecan, Carya illinoinensis
Peppertree Mix (Equal parts Schinus molle, Schinus terebinthifolius)
Pine, Australian (Beefwood), Casuarina equisetifolia
Pine, Loblolly, Pinus taeda
Pine, Longleaf, Pinus palustris
Pine Mix (Equal parts Pinus taeda, Pinus strobus, Pinus echinata)
Pine, Ponderosa, Pinus ponderosa
Pine, Virginia Scrub, Pinus virginiana
Pine, White (Eastern), Pinus strobus
Pine, White (Western), Pinus monticola
Pine, Yellow, Pinus echinata
Poplar, Lombardy’s, Populus nigra
Poplar, White, Populus alba
Privet, Ligustrum vulgare
Sweetgum, Liquidambar styraciflua
Sycamore, American, Platanus occidentalis
Sycamore, California (Western), Platanus racemosa
11 Tree Mix (Equal parts Fagus grandifolia, Platanus occidentalis, Ulmus americana, Juglans nigra, Salix nigra, Populus deltoides, Quercus rubra, Betula nigra, Carya ovata, Acer saccharum, Fraxinus americana)
Walnut, Black, Juglans nigra
Walnut, California Black, Juglans californica
Walnut, English, Juglans regia
Wax Myrtle, Morella cerifera
Western Oak Mix (Equal parts Quercus kelloggii, Quercus agrifolia, Quercus garryana)
Western 3 Tree Mix (Equal parts Olea europaea, Ulmus pumila, Platanus racemosa)
Western 10 Tree Mix (Equal parts Acacia dealbata, Acer negundo, Populus fremontii, Olea europaea, Ulmus pumila, Betula occidentalis, Juniperus occidentalis, Platanus racemosa, Quercus garryana, Morus alba)
Western Walnut Mix (Equal parts Juglans californica, Juglans regia)
Willow, Arroyo, Salix lasiolepis
Willow, Black, Salix nigra
Pollens - Weeds and Garden Plants
Allscale, Atriplex polycarpa
Amaranth, Green, Amaranthus hybridus
Baccharis Mix (Equal parts Baccharis sarothroides, Baccharis halimifolia)
Burningbush (Kochia), Kochia scoparia spp. scoparia
Burrobrush, Ambrosia salsola
Central/Western Weed Mix (Equal parts Kochia scoparia ssp. scoparia, Chenopodium album, Salsola kali)
Cocklebur, Xanthium strumarium
Common Weed Mix (Equal parts Xanthium strumarium, Plantago lanceolata, Chenopodium album, Amaranthus retroflexus, Salsola kali)
Dock-Sorrel Mix (Equal parts Rumex acetosella, Rumex crispus)
Dock, Yellow (Curly), Rumex crispus
Dogfennel, Eupatorium capillifolium
Goldenrod, Solidago canadensis
Iodinebush, Allenrolfea occidentalis
Lamb's Quarters, Chenopodium album
Lenscale (Quailbrush), Atriplex lentiformis
Marsh Elder, True (Rough), Iva annua
Marshelder, Burweed (Giant Poverty), Cyclachaena xanthiifolia
Mixed Amaranths (Equal parts Amaranthus hybridus, Amaranthus palmeri, Amaranthus retroflexus)
Mugwort, Common, Artemisia vulgaris
National Weed Mix (Equal parts Xanthium strumarium, Ambrosia trifida, Chenopodium album, Amaranthus retroflexus, Ambrosia artemisiifolia)
Nettle, Urtica dioica
Palmer's Amaranth, Amaranthus palmeri
Pigweed, Rough Redroot, Amaranthus retroflexus
Pigweed, Spiny, Amaranthus spinosus
Plantain, English, Plantago lanceolata
Plantain-Sorrel Mix (Equal parts Plantago lanceolata, Rumex acetosella)
Rabbit Bush, Ambrosia deltoidea
Ragweed, Desert, Ambrosia dumosa
Ragweed, False, Ambrosia acanthicarpa
Ragweed, Giant (Tall), Ambrosia trifida
Ragweed, Lanceleaf, Ambrosia bidentata
Ragweed, Slender, Ambrosia confertiflora
Ragweed, Western, Ambrosia psilostachya
Russian Thistle, Salsola kali
Sagebrush, Common, Artemisia tridentata
Sage Mix (Equal parts Artemisia tridentata, Artemisia ludoviciana)
Sage, Prairie, Artemisia ludoviciana
Saltbush, Annual, Atriplex wrightii
Scale/Atriplex Mix (Equal parts Atriplex polycarpa, Atriplex lentiformis, Atriplex canescens)
Sorrel, Sheep (Red), Rumex acetosella
Waterhemp, Tall, Amaranthus tuberculatus
3 Weed Mix (Equal parts Xanthium strumarium, Chenopodium album, Amaranthus retroflexus)
Western Ragweed Mix (Equal parts Ambrosia acanthicarpa, Ambrosia psilostachya)
Wingscale, Atriplex canescens
Plants and Plant Parts
Cotton Linters, Gossypium hirsutum
Cottonseed, Gossypium hirsutum (For Diagnostic Use Only)
Flax, Linum usitatissimum (For Diagnostic Use Only)
Gum, Arabic, Acacia senegal
Gum, Karaya, Sterculia urens
Gum, Tragacanth, Astragalus gummifer
Kapok, Ceiba pentandra
Orris Root, Iris germanica
Pyrethrum, Chrysanthemum cinerariifolium
Tobacco, Cultivated, Leaf, Nicotiana tabacum
Pollens - Cultivated Farm Plants
Alfalfa, Medicago sativa
Beet, Sugar, Beta vulgaris
Corn, Cultivated, Zea mays
Oat, Cultivated, Avena sativa
Rape (Mustard), Brassica napus
Red Clover, Trifolium pratense
Rye, Cultivated, Secale cereale
Wheat, Cultivated, Triticum aestivum
Pollens - Flowers
Daisy, Leucanthemum vulgare
Dandelion, Taraxacum officinale
Sunflower, Helianthus annuus
Molds, Rusts and Smuts
AHH Mold Mix (Equal parts Alternaria alternata, Bipolaris sorokiniana, Cladosporium sphaerospermum)
Alternaria alternata
Alternaria/Hormodendrum Mix (Equal parts Alternaria alternata, Cladosporium sphaerospermum)
Aspergillus amstelodami
Aspergillus flavus
Aspergillus fumigatus
Aspergillus Mix (Equal parts Aspergillus amstelodami, Aspergillus flavus, Aspergillus fumigatus, Aspergillus nidulans, Aspergillus niger)
Aspergillus nidulans
Aspergillus niger
Aureobasidium pullulans
Bermuda Grass Smut, Ustilago cynodontis
Bipolaris sorokiniana
Botrytis cinerea
Candida albicans
Chaetomium globosum
Cladosporium herbarum
Cladosporium sphaerospermum
Corn Smut, Ustilago maydis
Curvularia spicifera
Dematiaceae Mix (Equal parts Alternaria alternata, Aureobasidium pullulans, Bipolaris sorokiniana, Cladosporium herbarum, Curvularia spicifera, Helminthosporium solani)
Epicoccum nigrum
Epidermophyton floccosum
Fusarium Mix (Equal parts Gibberella fujikuroi, Fusarium solani)
Fusarium solani
Geotrichum candidum
Gibberella fujikuroi
Gliocladium viride
Grain Smut Mix (Equal parts Ustilago maydis, Ustilago tritici, Ustilago nuda, Ustilago avenae)
Grass Smut Mix (Equal parts Ustilago cynodontis, Sporisorium cruentum)
Helminthosporium solani
Hypomyces perniciousus
Loose Kernel Smut, Sporisorium cruentum
Loose Smut, Wheat, Ustilago tritici
Microsporum canis
Mold Mix #1 (Equal parts Alternaria alternata, Aspergillus niger, Bipolaris sorokiniana, Cladosporium sphaerospermum, Penicillium chrysogenum var. chrysogenum)
Mold Mix #2 (Equal parts Aureobasidium pullulans, Curvularia spicifera, Gibberella fujikuroi, Mucor plumbeus, Rhizopus stolonifer)
Mold Mix #3 (Equal parts Alternaria alternata, Aspergillus niger, Cladosporium sphaerospermum, Penicillium chrysogenum var. chrysogenum)
Monilia Mix (Equal parts Candida albicans, Neurospora intermedia)
Mucor circinelloides f. circinelloides
Mucor circinelloides f. lusitanicus
Mucor Mix (Equal parts Mucor circinelloides f. lusitanicus, Mucor plumbeus)
Mucor plumbeus
Neurospora intermedia
New Stock Fungi Mix (Equal parts Sarocladium strictum, Alternaria alternata, Aspergillus niger, Aureobasidium pullulans, Bipolaris sorokiniana, Botrytis cinerea, Candida albicans, Chaetomium globosum, Cladosporium sphaerospermum, Epicoccum nigrum, Gibberella fujikuroi, Mucor plumbeus, Penicillium chrysogenum var. chrysogenum, Phoma betae, Rhizopus stolonifer, Trichophyton mentagrophytes)
Oat Smut, Ustilago avenae
Paecilomyces variotii
Penicillium chrysogenum var. chrysogenum
Penicillium digitatum
Penicillium Mix (Equal parts Penicillium camemberti, Penicillium chrysogenum, Penicillium digitatum, Penicillium chrysogenum var. chrysogenum, Penicillium roqueforti)
Phoma betae
Phycomycetes Mix (Equal parts Mucor circinelloides f. lusitanicus, Rhizopus stolonifer)
Rhizopus arrhizus
Rhizopus Mix (Equal parts Rhizopus stolonifer, Rhizopus arrhizus)
Rhizopus stolonifer
Rhodotorula mucilaginosa
Saccharomyces cerevisiae
Sarocladium strictum
Stemphylium solani
Trichoderma harzianum
Trichophyton mentagrophytes
Trichophyton rubrum
Trichothecium roseum
Animal Allergens
Canary Feathers, Serinus canaria
Cattle Epithelia, Bos taurus
Chicken Feathers, Gallus gallus
Dog Epithelia, Canis lupus familiaris
Duck Feathers, Anas platyrhynchos
Gerbil Epithelia, Meriones unguiculatus
Goat Epithelia, Capra hircus
Goose Feathers, Anser anser
Guinea Pig Epithelia, Cavia porcellus
Hamster Epithelia, Mesocricetus auratus
Hog Epithelia, Sus scrofa
Horse Epithelia, Equus caballus
Mixed Feathers (Equal parts Gallus gallus, Anas platyrhynchos, Anser anser)
Mouse Epithelia, Mus musculus
Parakeet Feathers, Melopsittacus undulatus
Rabbit Epithelia, Oryctolagus cuniculus
Rat Epithelia, Rattus norvegicus
Silk Worm Cocoon, Bombyx mori
Insects (Whole Body)
Ant, Black Carpenter, Camponotus pennsylvanicus
Ant, Fire, Solenopsis invicta
Ant, Fire, Solenopsis richteri
Cockroach, American, Periplaneta americana
Cockroach, German, Blattella germanica
2 Cockroach Mix (Equal parts Periplaneta americana, Blattella germanica)
Deer Fly, Chrysops vittatus
Flea, Ctenocephalis felis (For Dagnostic Use Only)
House Fly, Musca domestica (For Dagnostic Use Only)
Mosquito, Aedes taeniorhynchus (For Diagnostic Use Only)
Food - Animal Products and Poultry Products
Beef, Bos taurus
Chicken Meat, Gallus gallus
Egg, White, Chicken, Gallus gallus
Egg, Whole, Chicken, Gallus gallus
Egg, Yolk, Chicken, Gallus gallus
Lamb, Ovis aries
Pork, Sus scrofa
Turkey Meat, Meleagris gallopavo
Food - Dairy Products
Milk, Cow, Bos taurus
Food - Fish and Shellfish
Bass, Black, Centropristis striata
Catfish, Channel, Ictalurus punctatus
Clam, Northern Quahog, Mercenaria mercenaria
Cod, Atlantic, Gadus morhua
Crab, Blue, Callinectes sapidus
Fish Mix (Equal parts Gadus morhua, Paralichthys lethostigma, Hippoglossus hippoglossus, Scomber scombrus, Thunnus albacares)
Flounder, Southern, Paralichthys lethostigma
Lobster, American, Homarus americanus
Mackerel, King/Atlantic, Scomber scombrus
Oyster, Atlantic/Eastern, Crassostrea virginica
Perch, Ocean, Sebastes alutus
Salmon, Atlantic, Salmo salar
Scallops, Sea, Placopecten magellanicus
Shellfish Mix (Equal parts Mercenaria mercenaria, Callinectes sapidus, Crassostrea virginica, Placopecten magellanicus, Farfantepenaeus aztecus)
Shrimp, Brown, Farfantepenaeus aztecus
Trout, Rainbow, Oncorhynchus mykiss
Tuna, Yellowfin, Thunnus albacares
Food - Plant Source
Almond, Prunus dulcis
Apple, Malus pumila
Apricot, Prunus armeniaca
Barley, Whole Grain, Hordeum vulgare (For Diagnostic Use Only, Contains SFS*)
Bean, Lima, Phaseolus lunatus
Bean, Navy, Phaseolus vulgaris
Bean, String Green, Phaseolus vulgaris
Blueberry, Velvetleaf, Vaccinium myrtilloides
Brazil Nut, Bertholletia excelsa
Broccoli, Brassica oleracea var. botrytis
Buckwheat, Fagopyrum esculentum
Cabbage, Brassica oleracea var. capitata
Cacao Bean, Theobroma cacao
Cantaloupe, Cucumis melo
Carrot, Daucus carota
Cashew Nut, Anacardium occidentale
Cauliflower, Brassica oleracea var. botrytis
Celery, Apium graveolens var. dulce
Cherry, Sweet, Prunus avium
Cinnamon, Cinnamomum verum
Coconut, Cocos nucifera
Coffee, Coffea arabica (For Diagnostic Use Only)
Corn, Zea mays
Cranberry, Vaccinium macrocarpon
Cucumber, Cucumis sativus
Garlic, Allium sativum
Ginger, Zingiber officinale
Grape, White Seedless, Vitis vinifera
Grapefruit, Citrus X paradisi
Hazelnut (Filbert), Corylus americana
Hops, Humulus lupulus
Lemon, Citrus X limon
Lettuce, Lactuca sativa
Malt (Barley), Hordeum vulgare
Mushroom, Agaricus campestris
Mustard Seed, Sinapis alba
Nutmeg, Myristica fragrans
Oat, Avena sativa (For Diagnostic Use Only, Contains SFS*)
Olive, Green, Olea europaea
Onion, Allium cepa
Orange, Citrus X sinensis
Pea, Green or English, Pisum sativum
Peach, Prunus persica
Peanut, Arachis hypogaea
Pear, Pyrus communis
Pecan, Carya illinoinensis
Pepper, Black, Piper nigrum
Pepper, Green, Capsicum annuum
Pineapple, Ananas comosus (For Diagnostic Use Only, Contains SFS*)
Potato, Sweet, Ipomoea batatas
Potato, White, Solanum tuberosum
Raspberry, Red, Rubus idaeus
Rice, Oryza sativa
Rye, Secale cereale (For Diagnostic Use Only, Contains SFS*)
Sesame Seed, Sesamum indicum
Soybean, Glycine max
Spinach, Spinacia oleracea (For Diagnostic Use Only, Contains SFS*)
Squash, Yellow Summer, Cucurbita pepo var. ovifera
Strawberry, Fragaria X ananassa
Tomato, Solanum lycopersicum
Vanilla, Vanilla planifolia
Walnut, Black, Juglans nigra
Walnut, English, Juglans regia
Watermelon, Citrullus lanatus
Wheat, Whole, Triticum aestivum (For Diagnostic Use Only, Contains SFS*)

*SFS – Sodium Formadehyde Sulfoxylate

16.2 Storage and Handling

Maintain at 2 to 8°C (36 to 46°F) during storage and use.

Dilutions of concentrated extracts that result in a glycerin content of less than 50% can reduce extract stability. Extract dilutions at 1:100 volume to volume should be kept no longer than a month, and more dilute solutions no more than a week. The potency of a dilution can be checked by skin test comparison to a fresh dilution of the extract on a known allergic patient.

17 Patient Counseling Information


Instruct patient to remain under observation in the office for 30 minutes or longer after an injection.

Caution patient that reactions can occur more than 30 minutes after skin testing or an injection.

Instruct patient to recognize the following symptoms as adverse reactions and to immediately return to the office or immediately seek other medical attention if any of these symptoms occur following skin testing or an injection:
  • Unusual swelling and/or tenderness at the injection site
  • Hives or itching of the skin
  • Swelling of the face and/or mouth
  • Sneezing, coughing or wheezing
  • Shortness of breath
  • Nausea
  • Dizziness or faintness

Manufacturer:

U.S. License No. 308

Greer Laboratories, Inc.

Lenoir, NC 28645 U.S.A

Package Label.principal Display Panel






DISCLAIMER:

"This tool does not provide medical advice, and is for informational and educational purposes only, and is not a substitute for professional medical advice, treatment or diagnosis. Call your doctor to receive medical advice. If you think you may have a medical emergency, please dial 911."

"Do not rely on openFDA to make decisions regarding medical care. While we make every effort to ensure that data is accurate, you should assume all results are unvalidated. We may limit or otherwise restrict your access to the API in line with our Terms of Service."

"This product uses publicly available data from the U.S. National Library of Medicine (NLM), National Institutes of Health, Department of Health and Human Services; NLM is not responsible for the product and does not endorse or recommend this or any other product."

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