What is the lowest maintenance dose you will use if a patient continues to have anaphylaxis when trying to achieve maintenance dosing?

Probably 1:1 0.2 ml. Most of the lesser dose maintenance patients are ones I inherited and had to go way back in the shot record to see what the indication for reduction was whether systemic vs long-lasting LLR or something else like an intolerance. I have a hard time believing that patients will achieve notable benefit maintaining at yellow but who knows there are always patients who report a benefit in earlier vials. And agree with the comment from Dr. @Dr. First Last De Asis - do they have an elevated baseline tryptase? Uncontrolled asthma? Secretly sprinting to the office beforehand?

Another approach might be to give a lower dose, perhaps 1.5 ml of a 1:1 every 2 weeks, so that the monthly dose would be a minimum of 0.3 ml.

George Gottlieb
Decatur GA

Was the patient evaluated for mastocytosis? Why is he or she getting anaphylaxis to usual doses of AIT?

I suppose this patient has had severe symptoms and has seen improvement on IT. Why else continue IT?

If the allergist is willing to share his extract "recipe", maybe there are some allergens in the dose in the extract that can be reduced.

Just a thought.

Seems like in this case of recurrent anaphylaxis, one should titrate the concentration and/or dose according to this individual's achievement of clinical tolerance and overall symptomatic improvement, before settling on a tolerable, effective maintenance dose.