Pink Book LDA Patient's Copy

LDA
Low Dose Allergen
Immunotherapy
Patient Instruction Booklet
How to regain your health through optimal immunotherapy
For patients treated with (ultra) Low Dose Allergen Immunotherapy
W. A. Shrader, Jr., M.D.
Fellow, American Academy of Environmental Medicine
Board Certified in Environmental Medicine
Jan 2018: 10th Edition
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1st Edition: May 2003
2nd Edition June 2005
3rd Edition July 2007
4th Edition February 2009
5th Edition January 2011
6th Edition February 2012
7th Edition September 2013
8th Edition May 2014
9th Edition Jan 2015
10th Edition Jan 2018
Copyright © April 2003 by W. A. Shrader, Jr., M.D.
All Rights Reserved.
This work (except for previously published and duly copyrighted material, with
permission of the copyrighting individual) may be reproduced on the condition that full
credit is given to the author.
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Table of Contents
ACTION OF LDA ................................................................................................................................... 5
ADMINISTRATION METHOD .................................................................................................................. 6
SAFETY ................................................................................................................................................. 6
FREQUENCY OF TREATMENT WITH LDA AND RESPONSE ...................................................................... 7
Reasons for Failure of LDA ............................................................................................................. 9
Disadvantages of LDA ................................................................................................................... 10
GENERAL RULES TO RECEIVE LDA ................................................................................... 11
OVERALL GUIDELINES ........................................................................................................................ 11
LEVEL 1: GUIDELINES FOR PATIENTS WITH ONLY SEASONAL HAY FEVER ....... 14
Do You Really Have Only Hay Fever? .......................................................................................... 14
Exertion & Temperature Do's and Don'ts ..................................................................................... 16
Food, Pollen and Mold Cross-Reactions ....................................................................................... 16
LEVEL 2: GUIDELINES FOR PATIENTS WITH FOOD AND OTHER MORE
COMPLEX PROBLEMS. ........................................................................................................... 17
LEVEL 3: GUIDELINES FOR PATIENTS WHO HAVE SIGNIFICANT CHEMICAL
SENSITIVITY .............................................................................................................................. 18
Transportation ............................................................................................................................... 20
Hotels/Motels ................................................................................................................................. 21
About Your Workplace During LDA Treatment (Level 3) ............................................................. 21
Chemicals at Work – for Patients Sensitive to Chemicals ............................................................. 21
LDA: REACTIONS AND SIDE EFFECTS ............................................................................... 22
IMMEDIATE AND LOCAL REACTIONS .................................................................................................. 22
DELAYED REACTIONS ........................................................................................................................ 23
DELAYED OR IMMEDIATE DEPRESSION ............................................................................................... 24
CIRCUMSTANCES WHEN YOU SHOULD NOT RECEIVE AN LDA TREATMENT .... 25
DRUGS OFTEN INTERACT WITH LDA ................................................................................................. 25
FOOD GUIDANCE FOR PATIENTS WITH MODERATE TO SEVERE FOOD ALLERGY OR INTOLERANCE .... 26
Fasting ........................................................................................................................................... 27
After the LDA Diet ......................................................................................................................... 27
Unmasking, Rotation Diets and the Very Mixed Diet .................................................................... 27
Food Idiosyncrasies ....................................................................................................................... 29
Boosting Tolerance ........................................................................................................................ 29
Stimulant Beverages ...................................................................................................................... 30
Vitamin C ....................................................................................................................................... 30
LDA AND GLUTEN SENSITIVITY .......................................................................................... 31
THE GUT AND LDA ................................................................................................................... 31
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CANDIDA: GUT PREPARATION AND ANTIFUNGALS ............................................................................. 31
ASTHMA, ECZEMA, ADHD, AUTISM.................................................................................... 33
Asthma ........................................................................................................................................... 33
Eczema ........................................................................................................................................... 34
Hyperactivity (ADHD, ADD) ......................................................................................................... 34
Autism ............................................................................................................................................ 34
RULES FOR IMMUNIZATION AND MALARIA PREVENTION ....................................... 36
DRUGS THAT WILL LIKELY INTERFERE WITH LDA: .................................................... 41
DRUGS AND TREATMENTS THAT HELP, MAY HELP OR DO NOT INTERFERE
WITH LDA: .................................................................................................................................. 42
DRUGS WHOSE EFFECTS ARE UNCLEAR ......................................................................... 45
THESE MAY ALSO INTERFERE WITH YOUR LDA TREATMENT: .............................. 45
LDA RECIPES ............................................................................................................................. 47
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Introduction to LDA – Low Dose Allergen Immunotherapy
This booklet, now known as the “Pink Book”, is written as a guide for patients
receiving LDA immunotherapy. Since there are a few rules related to LDA that
don’t apply to other forms of immunotherapy, I wrote this booklet to make it
simpler for patients doing LDA and to put the rules in one place. This booklet is
meant only as a guide, and your physician may have other ways of doing LDA
that are slightly different from those in this booklet.
I feel very strongly that LDA is far superior to other methods of allergy
treatment, and it offers a unique treatment for many autoimmune diseases that are
only otherwise treatable only with drugs, many of which are hazardous.
LDA was developed from EPD immunotherapy, invented by the most brilliant
allergist I’ve ever known, from Great Britain, Dr. Leonard M. McEwen.
Action of LDA
LDA is a method of immunotherapy that involves desensitization with combinations
of a wide variety of extremely low dose allergens (approximately 10-17 to approximately
10-6), given with an enzyme mixture containing beta-glucuronidase. The enzyme mixture
acts as a lymphokine, better signaling the immunizing effects of the allergens. LDA
induces the production of “activated” T-regulator cells.
Since LDA is compounded under my direction by a large compounding pharmacy,
and used by prescription for specifically named patients, it is not regulated by the FDA
the same way as a product sold by commercial manufacturer. It is legal for patients and
physicians to use, as long as it’s prescribed properly.
“Classical” immunotherapy for hay fever, dust mite or other IgE-mediated allergies is
largely antibody-mediated, and “neutralization” therapy likely works through low dose
tolerance, so both of these methods are generally not long lasting and cannot easily be
discontinued without the partial or complete return of symptoms. Medications are
frequently required routinely with the former, while avoidance is usually necessary with
the latter.
LDA immunotherapy, however, is primarily cell-mediated by T-regulator cells.
Since T-cells have a half-life of perhaps up to 80 days, although this figure is unclear,
LDA creates a much longer lasting desensitization than the conventional immunotherapy
used in the USA. Patients generally need fewer medications, and avoidance of allergenic
substances such as pollens and foods is much less necessary.
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Administration Method
LDA is administered by one or more tiny intradermal injections (into the skin itself),
usually on the inner aspect of the forearm, though it may be given on the legs, upper arms
or abdomen. Some physicians are using it sub-lingually (under the tongue), but there are
no long-term studies validating this. It appears to work.
Safety
There has never been a fatal or life-threatening systemic reaction to LDA treatment.
The dosage is simply too low for life-threatening reactions to occur, and indeed LDA can
be used to treat anaphylaxis to peanut and shrimp.
LDA includes mixtures of over three hundred allergens that act quite “universally.”
This means that patients allergic or intolerant to most substances, and with quite diverse
medical conditions, can respond to treatment. Available LDA mixtures include inhaled
pollens, danders, dust and mites, fungi, yeast (including candida species), molds, foods,
many food additives, most common chemicals and perfumes (except pesticides and
herbicides) and formaldehyde.
LDA food and inhalant mixtures are universally cross reactive, and Dr. McEwen put
every possible allergenic component into his original EPD. The mixes are proprietary, so
please don’t bother asking your LDA physician whether it contains particular substances
to which you are allergic. No matter what they are, the proteins in LDA are selected to
cover everything.
Since LDA does not contain pesticides or herbicides per se; patients who experience
adverse responses to these agents alone, and not to other related excitants or allergens,
will not receive significant benefit from LDA. However, these patients are rare, and if
such a patient additionally has concurrent food, chemical and inhalant problems, the
results can be good.
LDA is the only real immunotherapy that can be used to treat true (IgE-mediated)
food allergy, such as life-threatening reactions to peanut and shrimp (anaphylaxis).
LDA should not be used during pregnancy. There is no evidence that LDA could be
harmful during pregnancy, but as we know, anything can happen with pregnancy and
childbirth, and if a patient is on LDA, they could place the blame there. If a patient elects
to be treated when she is pregnant, precautions must be taken with drugs used in
conjunction with LDA, such as most antifungals and Vitamin A, and probably even a
simple substance like bismuth, if it is used, could harm a developing baby.
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Frequency of Treatment with LDA and Response
Since T-cells have a long half-life, LDA treatments need only be given every 2
months at first, then less often. Generally, patients with most conditions are treated every
two months for six to eight times, or about a year. After that, treatment intervals
generally increase. Children usually require less treatment and can more easily stop
treatment then can adults.
Although rare, hay fever strictly due to seasonal pollen allergy is initially treated
with 1 to 3 doses per year. It is preferable to get the first injection 3 to 4 months before
the onset of the season, and a booster dose 2-3 weeks before the season peaks. After the
first season, only one booster dose may be required yearly, given 3 weeks before the
season starts. However, for some patients, treatment every two months is necessary to
create immunity. The best results are seen when LDA is started about a year before the
allergy season for any particular patient.
Most allergies, including food allergy or intolerance, tend to be less simple. Initial
doses tend to be at 2-month intervals for the first six to eight treatments. Subsequently
the frequency of the desensitization can be reduced. LDA injections cannot be given
more often than every 7 weeks. Foods that cause the most adverse reactions, such as milk
and wheat, usually take the longest time to desensitize completely.
When the response is well established and patients feel pretty well for the whole two
months between treatments, generally between the sixth to the eighth dose (fewer doses
in children), the frequency of treatment for most illnesses may often be extended to every
three months, then every four months, and so on.
Our study of over 10,000 patients showed that half of the patients with multiple
problems can stop LDA completely after 16 - 18 doses. The other half can at least go for
long intervals (1-4 years) between treatments after that time. Children usually respond
more quickly and may stop sooner.
How Long Does It Take To Improve?
The effect of LDA is usually immediate, and 70 % of patients feel well immediately
after their first treatment. If not, most patients respond by the third treatment. However,
the full benefit of LDA will take longer. In particular, some patients with food allergy or
intolerance may only notice sustained improvement only after three to six doses, i.e. 6-12
months from the start of treatment, and severely reactive foods may take two years to
become tolerable in moderate to large amounts. For the rare patient, a few foods may not
totally desensitize.
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The response to LDA has two distinct phases after an injection:
1. Immediate Reaction: An immediate temporary “cure” of symptoms may result
after LDA. This may begin immediately after the first treatment and usually
should last 2-5 weeks. Two to three weeks of significant improvement is typical
with the first two to three treatments, after which symptoms begin to return. One
may see this for the first several treatments. The first shot that should “work” —
at least to some degree — for most patients will be either the first, second or
third. A positive response to the first injection occurs on an average about 70%
of the time, a "neutral" response about 23%, and a "poor" response about 7%.
Response rates generally improve with subsequent injections. If there is no
response at all (better or worse) by the third treatment, there could be a problem
that your physician should look into. No response by the 6th treatment is rare, but
means LDA will usually fail.
Some patients do not feel well shortly after they start the “LDA Diet”, and
after the first to third treatment may have a few days of not feeling well. Vitamin
B-complex injections work well for children who are severely nauseated when
they go on the LDA diet.
Rare patients (about one in 20) do not feel well for the first 2-3 weeks
after their initial treatments. I tell patients to try very hard to ignore
unpleasant symptoms that occur in the first days to three weeks after
treatment, and not call their physician about every weird symptom that
might develop. These will usually improve dramatically by three weeks,
and will happen much less (or never) with subsequent treatments.
2. Delayed Action: This should begin after 3-4 weeks (after the lymphocytes
mature) and may last to some degree for 2 to 4 months at first, then much longer
later on in treatment. This response begins usually between the sixth and eighth
treatment, when there may be no apparent immediate response to the shot, but as
lymphocytes mature, more and more positive effects are noted. Occasionally I
see a patient who has this response with the first treatment. In either case,
patients may complain for 3 weeks after a treatment, only to find their shot
“kicks in,” almost like magic, at about 3-4 weeks.
Once the first injection takes effect, you should note you feel better in many ways
usually for 2 to 5 weeks. When the injection begins to wear off, your symptoms will
return to some degree and you must wait until the next injection for a continued response.
There may be a decrease in response to any LDA treatment, after which continued
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improvement is again noted. The reason for this is unknown. You cannot receive an
LDA treatment sooner than 7 weeks from the last.
The period of improvement should lengthen over time, and gradually you should feel
quite well for the whole 2-month period between injections. When this happens, you can
begin to stretch the interval between LDA injections. This will generally occur in adult
patients somewhere between 6 to 8 injections (about a year). Children should be able to
stretch their injection intervals sooner. It is better to go longer and begin to have
symptoms than it is to get a treatment “early” for some convenience (travel, etc.).
WARNINGS: If you have any history of eczema, skin allergy of any kind, hives, swelling
of the lips, face or body, autoimmune disease, or especially anaphylactic reactions or
anaphylaxis, be certain the doctor knows about this before you ever receive LDA: it is
often important that this type of patient receives prednisone prior to at least the first
treatment, and perhaps for several subsequent treatments.
Also, if "neutralizing" or standard immunotherapy is administered as the first several
LDA injections appear to "wear off," there is evidence that this could destroy the success
of LDA immunotherapy.
Reasons for Failure of LDA
The primary reasons (in order of decreasing importance) for failures of LDA I have seen
are:
 Improper dosage – most commonly under-dosage of foods. This is the most
common reason LDA may not seem to work very well at first, or, more
commonly, stops working after a treatment or two. This is sometimes
unavoidable, since certain patients (those with anaphylaxis, eczema), MUST be
started on the low LDA foods (LX). Often that will be the correct dose, but if
your LDA works less and less better, you likely need a dose increase.
 Failure for some patients to follow the more important “rules” for LDA.
Medications are the principal reason for this type of failure.
 Low Vitamin D levels. This can be checked with a blood test.
 Silicone breast or other implants, active infection (e.g. in a root canal), or other
immunological issues. Women with breast implants, either silicone or salinefilled,
have been known to fail on LDA. Sometimes even removal of the
implants may not solve the problem, as it takes years for silicone antibodies to
clear, and if there has been implant leakage, they may never clear.
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 Rare: Interference by organisms from the gut, usually yeast, and/or improper
patient preparation for this problem.
 Rare: Interference from extremely high levels of heavy metals (even patients who
have had their dental amalgams removed are not exempt from this problem),
 Occasionally LDA fails for reasons we do not understand.
Disadvantages of LDA
The disadvantage of LDA is that it generally may take 6 to 8 injections to achieve a
sustained effect that lasts for the full two months between injections (except for simple
dust and pollen allergy, which usually requires fewer injections). LDA cannot be
considered to have failed until 6-8 treatments have been given without any benefit. Even
then, there is often “delayed” success 6 months or so after the treatments are stopped.
Rare patients have very little response until they have had 6 treatments.
NEVER PLAN TO START LDA UNLESS YOU’RE WILLING
TO BE TREATED FOR 12 MONTHS BEFORE
YOU MIGHT SEE LASTING RESULTS
This having been said, you should see relief long before then. I have found that LDA
tends to give more permanent relief than any "standard" form of immunotherapy I’ve
ever used.
To protect the result of LDA from being disturbed, it may be necessary for you to
follow some of the guidelines discussed in this booklet around the time of treatment.
Failures of LDA are often due to non-observance of one or more of the rules in this
booklet.
Medications, some herbals, homeopathics, other treatment modalities, and activities
not “restricted” in this booklet should be considered to be "unknowns." My best advice,
especially if you have significant illness, is to avoid “questionable” things for 3 weeks
after an LDA injection whenever possible.
If we don’t know whether newly developed medications and those not listed in
this Booklet will cause LDA to fail, my general advice is: 1) Avoid it for three days
before LDA and three weeks after, 2) If you are unable to do this, avoid it for the
three critical days around LDA, 3) If you are unable to do this, avoid it for the day
before and the day after LDA, and 4) if you absolutely must take it all the time, I
advise that you take it all the time. However, if your LDA fails, you must then look at
this as the primary reason and find a substitute for the medication.
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General Rules to Receive LDA
Overall Guidelines
In order for LDA therapy to work well, for most patients the most
important guidelines to follow are the food and diet guidelines and to the drugs to
avoid, discussed in this booklet.
The success rate of LDA depends partly on factors that interfere with it. The
guidelines in this book are meant to help make this treatment work best.
LDA is an extremely low dose immunotherapy. Since the dose is so low, there are
factors that can interfere with your response to it. Other low-dose forms of
immunotherapy have the same problems. The lower the dose, the more potential there is
for interference form “outside” things.
Interestingly, there are patients who do very little to try to help the therapy succeed
and it works well. On the other hand, some patients need to follow most guidelines in
this booklet in order to insure their treatment works well.
Some physicians do not follow the standard dietary (or other) rules of LDA and seem
to have success. Whether this success is less than would be seen if their patients had
followed to rules has not been determined. My advice for patients is to follow the rules,
since Dr. McEwen made them in the 70’s. Short of that, I tell patients to follow the rules
at first. Once they see how LDA should work for them, they could certainly experiment
later.
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THE BASIC LDA DIET – For Level 2 and Level 3 Patients
I will mention the "3 critical days" frequently in this booklet. This term
means the day before LDA, the day of LDA and the day after LDA.
You should eat ONLY:
 Lamb, rabbit, venison (only if you rarely or never eat it) or white fish (if you are not
specifically allergic to it). Some other unusual meats may be acceptable. Discuss
these with your physician. Salmon is probably a poor idea due to the high omega 3.
 Sweet potatoes (any type) or yams
 Parsnips, rutabagas, tapioca root products or cassava root, manioc, yucca, sago
(turnips OK for some)
 Cooked carrots, celery and cabbage
 Potatoes – any type – (may be a problem for some patients)
 Lettuce – any type, but no other greens – raw (outer leaves only) or cooked (all
leaves OK)
 Tapioca granules, flour or starch, plain (see tapioca wafer recipe in recipe section)
 Rhubarb
 Pure Baking soda (without additives)
 Sea salt: plain sea salt (non-iodized – do not use "regular" salt).
 Bottled, R/O, filtered or purified water, flat or fizzy for drinking and cooking
Note: no margarine is safe to use during the 3 critical days. Avoid all margarine
and all other seasonings totally. The only seasoning permitted is sea salt, such as
Haines'® brand in the yellow container (do not use the iodized kind).
NOTE: Any food not listed above is unsafe to eat in any quantity during the critical
three days. This includes medications (unless advised by the doctor), herbs,
beverages, chewing gum, and any other things you might put in your mouth; and no,
sorry, coffee and tea are NOT allowed!
Children under the age of 8 may have trouble with this diet because of food
withdrawal. They may experience nausea and vomiting. Consult the doctor if your
child is receiving LDA (remember B-complex injections).
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Note: For LDA to work well, you need to have relatively normal levels of
Vitamin D in your body (blood). This can be determined by a simple blood
test. Your Vitamin D level should optimally be about 40. If not, ask your
doctor about Vitamin D supplementation and re-check your level.
There are three levels of rules with guidelines to follow for patients with
different types of problems discussed in this booklet.
Level 1: Guidelines for Patients with ONLY Seasonal Hay Fever
Do You Really Have Only Hay Fever?
NOTE: Very few patients have only "simple" hay fever and may be classed as Level
1. The following questionnaire should help you determine this. If you really have
only seasonal allergy, your answers should be the ones in italics below; if they are
not, you are very likely Level 2.
1. Symptoms in: Spring and/or Fall ONLY? yes/no
2. Eyes affected? yes/no
3. Nose affected? yes/no
4. Chest affected? yes/no
5. Swelling/tingling in mouth after any food? yes/no
6. Winter symptoms? yes/no
7. Eczema/skin rashes? yes/no
8. Irritable bowel syndrome yes/no
9. Severe problems with any chemical odors? yes/no
10. Gastrointestinal symptoms? yes/no
11. Headaches/Migraine? yes/no
13. Close family members with hay fever? yes/no
14. Do your symptoms clear up completely in winter? yes/no
15. Have you been told you have "Candida"? yes/no
So if your answers to the questions above are not the ones in italics, you very likely
have food or other problems, and you almost certainly need to follow stricter guidelines
(usually Level 2).
At the time of LDA:
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 Avoid alcohol for 10 days after treatment. You may cook with it as long as it is
heated enough to evaporate the alcohol before it is served.
 Don’t snuggle with your pets (especially cats) and avoid indoor molds at the time
of treatment. Try to limit your exposure to pollens and dust 12 hours before and
36 hours after LDA (for example, don’t sleep with your cat or dog during that
time). If you receive LDA inhalants near a pollen season, and you are
experiencing symptoms outdoors, you may need to extend that time.
 If you have ever had a water leak in your home and mold was discovered, you
might do best to stay elsewhere during the three critical days.
 You may exercise as you normally would during LDA, but avoid fatiguing
exercise, extreme heat, and sunburn for 3 days after LDA.
 Follow the rules for drugs known to interfere with LDA and immunization.
 Do not put ointments, creams and lotions on the site of the injection(s) on the day
of treatment.
 Use an unscented soap and shampoo (e.g. Magick Botanicals shampoo or similar)
on the day you receive LDA (or the night before if you bathe at night).
 Do not wear perfumes or other scented agents to the office on the day of LDA
(this is partly to protect your doctor’s patients who have chemical sensitivity).
 Avoid yard-work for the three critical days.
 If you know you are allergic to your pets (especially cats), and your pets spend
time inside the house, you should not stay in your home during the three critical
days. Wash your hands after handling your pet. The danger is sensitization to a
pet, and this has been shown to occur in rare patients, usually after 3 to 6
injections. If this does happen, the sensitization can be reversed with the next
LDA, but stricter guidelines must be followed. If you are not allergic to your
pets, try to keep them out of the bedroom and don’t snuggle your face into your
pets’ fur.
 If you are allergic to feathers, do not sleep with a feather pillow or down
comforter for at least a week after LDA. Use a cotton or foam pillow.
 Do not have LDA if you are trying to get pregnant within 2 weeks of the
injection.
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Exertion & Temperature Do's and Don'ts
For one week after LDA:
 Do not take a sauna
 Do not do excessive sunbathing. Sunbathing more than 5 days before LDA is
likely to be an advantage (enhances Vitamin D production in the skin).
 You may use ChapStick® during the three critical days, but probably best to
avoid it on the day of LDA.
 You may wear make-up during this time
Do your best to avoid high concentrations of mold spores indoors: mold floats
indefinitely in the air inside houses that are damp, suffer from condensation, smell musty
or even have had a leak or water damage in the past. Keeping the door of a damp room
or cellar shut is not likely to give effective protection, since the spores float so well in the
air. If you have a mold problem, keep windows open night and day while you are in the
house, if possible, to reduce your exposure. It is sometimes best to stay at a friend's dry,
modern, mold-free house with no pets for the day before, the day of and the day after
LDA. If your house is extremely damp and there has been any evidence of mold, you
should try very hard to get away from it during this time. Don’t worry about outside
mold.
Food, Pollen and Mold Cross-Reactions
Patients who suffer from allergy to tree pollens, especially birch or ironwood, must
not eat nuts, fresh apples and oranges, raw carrots or celery for about a week after LDA,
if those pollens are in season in your part of the country (spring). Mold spore allergens
from different species may cross-react with LDA. If you are allergic to inhaled mold
spores, avoid tea, cheese, and other fermented or aged foods for 10 days after LDA. If
the desensitization is unsuccessful, discuss the use of an antifungal regime for your next
LDA treatment with the doctor.
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Level 2: Guidelines for Patients with Food and Other More Complex
Problems (in addition to, or instead of seasonal allergy) Note: Most patients
are in the Level 2 category.
If you are a patient who has intestinal, food issues or autoimmune disease, may or
may not have pollen allergy, and do not have significant chemical sensitivity, the
guidelines you will follow appear in this section.
Also, if you think you only have pollen allergy and you have a sub-optimal response
to LDA on the Level 1 regimen, you must strongly consider following more of the Level
2 or 3 guidelines in this booklet. If you’re not sure which category you belong, discuss it
with the doctor.
So, if you have problems other than simple hay fever, you must follow all Level 1
guidelines, AND in addition:
Before LDA:
 Again, you must also follow all Level 1 guidelines
 Take a good multivitamin/mineral supplement, approved for LDA (less than 500
mg. of Vit. C – not during the three critical days).
 Use an appropriate bowel preparation for candida, if determined necessary by the
doctor. If you have toenail or fingernail fungus, tell your doctor!
 Take zinc 20-30 mg. daily, in addition to the amount you may be receiving in
your multiple vitamins for a week before and three weeks after LDA.
 Take magnesium (citrate or glycerinate, preferably), 200 mg./day in addition to
the magnesium you may be receiving in your multiple vitamins, for a week
before and three weeks after LDA.
On the day of LDA:
* Do not wear lipstick or eye-liner (or any make-up that might get in your eyes) on
the day of LDA.
* Do not put anything in your mouth except the foods permitted on the LDA diet
Critical three days:
* Follow the LDA Diet
* Do not use ChapStick® or other lip balm on the day of LDA.
* Use unscented soap only.
* Use unscented shampoo and conditioner.
* Do not use toothpaste. Use pure baking soda instead.
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* Sexual activity may be a problem, especially in women, since they risk
sensitization to their husbands' semen. This seems a particular risk for eczema
sufferers. Intercourse probably should be avoided for the critical 3 days of LDA
therapy.
* Minimize your exposure to animals, perfumes, aerosols, sprays, painting, etc.
* Never take any vitamins, minerals or other supplements during the three critical
days, and only take meds you discuss with your physician.
After LDA
* Avoid foods that have caused you to have significant symptoms in the past for
three weeks after LDA. This does not necessarily include foods for which you
had a positive blood test unless you know you react badly to them.
* Optional: Folic Acid, 10 mg. daily, may be taken to attempt to enhance the effect
of LDA for 30 days after LDA (side effect: possible nausea, so take with meals).
Vitamin and Mineral Supplements
Certain vitamin and mineral supplements theoretically improve the effect of LDA.
These supplements act primarily by affecting the T-cell receptor sites we are stimulating.
The following recommendations for supplements may be important for patients who have
moderate to severe problems. These should be taken along with an approved
multivitamin and mineral. Patients with milder problems, and kids under the age of 12
generally do not require these supplements. Patients with mild problems should probably
only take the supplements directed. Discuss this with the doctor if you aren’t sure
whether you should take any or all of these supplements. Vitamin D seems particularly
important, and all adults should probably take 2000 to 3000 IU per day.
Level 3: Guidelines for Patients Who Have Significant Chemical Sensitivity
(in addition to, or instead of the preceding problems). This is the least
common Level. Level 1 and Level 2 patients do NOT need to follow these following
guidelines, so if you do not have significant chemical sensitivity, skip to “LDA:
Reactions and Side Effects”.
Those of you with significant chemical problems should follow all of the preceding
instructions in this booklet for Level 1 and Level 2 patients. “Significant” means that
you are made ill for day or more when you are around perfumes or other scented agents,
you probably can’t go to the store without becoming ill, or your primary problems have
to do with exposure to various chemicals. In addition, our advice is that you follow the
remainder of these guidelines in this booklet as closely as possible, at least for the first
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several injections. Later on, especially after you've had 6-8 injections, you might be able
to be less careful about these rules.
You should do as well as you are able to adhere to the instructions without totally
disrupting your life. Whether you do or you do not have chemical sensitivity, mild
chemical exposures or chemical exposures for a brief time will not affect your LDA.
In addition to Level 1 and 2 guidelines, you should also do the following:
For at least 12 hours before and 2 days after LDA (preferably 3 days after):
* Do not read the newspapers, glossy magazines, or new books.
* Use no insecticides that produce vapor or might be breathed in: sprays, aerosols,
etc. Use traps or bait if you must have insect control.
* For cockroaches, etc., use boric acid and put it in the cracks under the skirting or
molding, etc., where the insects hide. The protection is long lasting and unlikely
to cause problems.
For the Three Critical Days:
* Avoid ointments, creams and lotions on any part of the body, especially
anywhere near the site(s) of the injection(s). This includes "homeopathic"
creams and ointments, as many contain agents that are problematic.
* Use no aerosols, spray polishes or perfumed sprays.
* Use no scents (perfumes, etc.) or air fresheners of any kind.
* No chemical deodorants. Use a mineral rock crystal (such as The Body Crystal®)
or baking soda during this time. At other times, use "natural," non-aerosol
deodorants made without aluminum compounds (look in health food stores).
* Makeup should not be used during these three days. If you choose to use it, it
should be kept to the absolute minimum, not perfumed, and not near the eyes.
Use only non-scented, "hypoallergenic" types. You run the risk of becoming
sensitized to makeup if you are sensitive.
* No bath oil, liquid soap, dishwashing or laundry liquid/powder, especially on the
hand of the treated arm. Use plastic or vinyl -- not latex -- gloves for
unavoidable washing dishes, etc. (many physicians have these available for
purchase in their offices).
* No hair sprays, hair mousse, hair conditioners or hair oils.
* Avoid tobacco smoke
* Do not do laundry on the day of your treatment. If you do, avoid inhaling
scented washing powders, soaps, bathroom cleaners, etc. You can avoid scented
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laundry detergents and scented fabric softener if you use unscented agents, such
as Downy Free® and Cheer Free® or other natural detergent.
For one week after LDA:
* If you have a hypoallergenic lotion you use that you know is safe, you could
begin to use it after the critical three-day period. Some patients, however, will
have a problem if these are used in the week after the three critical days, so be
cautious.
These restrictions may be difficult for patients with eczema. Discuss this with
the doctor.
Two to Three Weeks After LDA
 Avoid new carpets, new vinyl wallpaper, smelly plastic sheeting (new shower
curtains, etc.), and new furniture.
* Avoid smelly or new paint. The newer latex paints may be OK.
* Avoid insecticides that produce vapor or might be breathed in: sprays, aerosols,
etc. Use traps or bait if you must have insect control.
* Avoid situations where you cannot control your environment, such as attending
parties, going to church (perfume exposure), entering department stores, etc.
* No medicated shampoos for 2 weeks after LDA!
For one week before and two weeks after LDA:
* No permanent waving, hair coloring or other extensive hair treatment.
Hairdressers' salons are always full of scents and fumes. Avoid totally during
this time.
Transportation
Since many patients travel to get their LDA injections, the question of transportation
arises. We have found, even with patients with fairly severe chemical sensitivity, brief
exposure to exhaust fumes from cars, busses, etc., don't seem to interfere with LDA.
However, it would seem wise to take the following precautions:
* Don't sit next to a smoker or ride in a car with someone smoking, or with
someone wearing perfume or heavily scented agents.
* Avoid traveling in new cars; it's preferable to travel in an older car with an air recirculation
system.
* If you travel by air and have severe chemical problems, it would be wise to wear
a chemical-type respirator in the airport if necessary, in jet-ways while
disembarking and in the planes themselves until at least 5 minutes after takeoff.
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Hotels/Motels
One of the greatest problems for our patients from "out of town" with severe adverse
reactions to chemicals/"MCS" is finding a "safe" place to stay. Usually one of the office
staff can direct you to the most chemically free hotel(s) in the vicinity. If worse comes to
worst, some of you may even need to "camp out" during the 3 critical days in those areas
of the country where temperature allows.
The rules and regulations regarding LDA are summarized in a chart that will be
available from our office and appear in this booklet.
About Your Workplace During LDA Treatment (Level 3 ONLY)
Chemicals at Work – for Patients Sensitive to Chemicals
If you have a history of problems with adverse reactions to things in your work or
home environment, you must use caution when returning. If, for example, smoking is
allowed in your workplace and you have had significant problems when exposed to
smoke, you need to stay away from work on the day of the injection, and preferably at
least the day after. Two days after would be even better.
Work hazards that often cause problems for patients are some of the following:
perfumes, cigarette smoke, sick buildings, industrial complexes which produce products
with significant chemical odors, or those using chemicals, such as print shops, foundries,
welding, soldering, etc.
If your office is a small, enclosed space (without a window to the outside) with a new
computer, a fax machine, blueprint machine, laser printer or copier, it is best for you to
avoid it for at least 24 hours after the first few injections. 2 days’ avoidance after LDA
would be best for the first three injections.
A good rule of thumb would be to try to have your LDA injection near a weekend for
the first 3 injections. If you are chemically sensitive and work with many of the materials
mentioned above, it would be a good idea to do this for the first year of therapy.
Some patients may experience an immediate "panic"-type response when exposed to
some chemicals. If this occurs after an injection, it doesn't usually mean enough of the
chemical has been absorbed to upset LDA, providing you can remove yourself from the
chemical after a brief exposure.
Basically, patients who know they are upset by allergens or chemicals at work should
not return to it for at least 24 hours (and preferably 2 days -- but that's often not possible)
after an LDA treatment.
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Note: Remember, if you are not significantly sensitive to chemicals, you do not need
to follow Level 3 guidelines above. However, a prolonged or heavy exposure to any
chemical could adversely affect the response to LDA in any patient.
This is the end of the section discussing “levels”.
LDA: Reactions and Side Effects
Immediate and Local Reactions
Most reactions to LDA consist of local redness and swelling. The doses of allergens
contained in LDA are so small that the chance of a true acute generalized allergic
reaction is so extremely remote that it has never occurred. Immediate reactions to the
inhalant component of LDA (I or IC), with swelling of the entire forearm do occur
occasionally. These may be treated with a cold cloth. Do not use ice!
23
Although rare, swelling involving a whole forearm is the major significant local
reaction after LDA. A local reaction is generally associated with a good immunological
response. It should not be treated, but, if severe, Tofranil® (or generic imiprimine)
should be tried. Before you take any medication after an LDA injection, contact the
doctor’s office if this should happen. Do not use any local treatment on the swelling
besides a cold compress! Continue to use the arm normally.
Local reactions rarely persist for more than 3 days and should be subsiding
noticeably by the fourth day. Occasionally, the site(s) of the injection(s) may become
inflamed off and on for 3-4 weeks after an LDA injection. This probably indicates
exposure to allergens in the LDA mixture. If local reactions are recurrent and significant,
preparation with a low dose of prednisone may be helpful.
Prudence dictates that all patients who receive treatment with LDA must remain
under observation in the office for 20-30 minutes, at least after their first few treatments.
Delayed Reactions
Delayed reactions are unpredictable but not uncommon with LDA. They may start
between 2 hours and 5 days after a treatment. They usually last a few days, very
occasionally up to 3-4 weeks, and rarely for up to 2 months. When they occur, these
reactions happen usually after the first LDA treatment and diminish with successive
treatments. However, a delayed reaction may develop after any dose of LDA, but
subsequent doses may often cause no reaction. These reactions are usually a good sign
since they are generally followed by a favorable response to treatment.
The symptoms are usually a temporary return of the allergy symptoms that are being
treated. They should be controlled with Tofranil® (or generic imiprimine) when
possible, or by avoidance of the offending allergens (if known) until the reaction
subsides. Never use decongestants or antihistamines for 3 weeks after LDA. When in
doubt about a medication, ask!
These symptoms almost never require more treatment, although they may seem
worse than the original illness. Please remember not to panic if you feel like you have
the “flu” for a few days after your LDA treatment, since this may happen.
Very rarely, a delayed reaction takes the form of an allergic response you have not
normally experienced, usually a stuffy or runny nose or hives. This is likely to be mild
and transient.
Some patients develop headaches within a few days after LDA. Do not take aspirin
or any other pain reliever, since these will wipe out the effectiveness of the shot. Please
ask the office staff or the doctor about headache treatment alternatives.
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Delayed or Immediate Depression
This is rare, but has been known to occur after an LDA injection. It usually begins 1-
3 days after an injection, but may begin several weeks after an injection. It may persist
from 3 days to one month, rarely longer. If you have any history of a tendency towards
depression, a single dose of imiprimine, 25 mg. should be taken 5 minutes before at least
your first 1-3 LDA injections. If you experience this type of reaction after an LDA
treatment, the same treatment prior to your next injection likely will block this response.
Imiprimine does not interfere with your shot when taken at this time. If you are known to
be extremely sensitive to tricyclic antidepressants or any medications, the dose might best
be 10 mg.
If the imiprimine is taken even as late as half an hour after an LDA treatment, it won't
work for this delayed-onset depression, so be sure to ask the doctor to give you a
prescription so you can bring the medicine with you for your injection.
Imiprimine also works as the best substitute for antihistamines in the three week
period after LDA when regular antihistamines are not allowed. So don’t forget to get a
prescription for it if you commonly have these symptoms and need relief during this time.
If you are male and have prostrate issues, imiprimine will likely make those worse.
If LDA caused you to be more depressed than usual, you may take it (25 mg.) up to
three times daily at any time after LDA.
For rare patients, imiprimine could cause agitation, insomnia or other unusual
symptoms, especially if you react badly to antihistamines in general. If this happens,
STOP the medication and contact your LDA physician.
25
Circumstances When You Should NOT Receive an LDA Treatment
Do NOT Have a Dose of LDA
 If you are significantly allergic to a specific spring or fall pollen, and your shot is
within about a week of either side of the peak of that specific pollen season.
 If you have a chronic toenail or fingernail fungal infection and you haven’t taken
an azole antifungal in preparation for your LDA treatment
 If you are in the first three days of a cold, have any other infection or suspect that
you might be developing one. Use whatever natural agents (chymotrypsin,
echinacea, propolis, etc.) you can to treat the infection, and if they fail, you may
need an antibiotic. If you are given an antibiotic, be sure to take nystatin with it.
If you can get over the infection in time, you may still be able to receive LDA.
 If you are pregnant or think you might be pregnant. If you are trying to have a
baby, plan on receiving your LDA treatment only during the first two weeks after
a period, if possible. If you become pregnant on LDA, advise your doctor. There
have been many pregnant women who have received LDA without any adverse
effects. On the other hand, pregnancy generally carries more risk that a “normal”
state, so we feel it would be unwise to do LDA during pregnancy.
 If you have taken any pain killer like aspirin or Tylenol® , NSAIDS or others in
the past four days (don't take any for the next three weeks, either).
 If you have just been immunized (See "Rules for Immunization and Malaria
Prevention”).
 If you are taking any of the drugs which might upset LDA (see text, chart and
specific drug interactions).
 If you have had dental work with a local anesthetic (fillings, etc.) 3 days before
LDA, or you plan it within 2 weeks after LDA. Cleaning, small fillings without
anesthetic or checkups at the dentist’s office are OK.
 If you are food allergic or intolerant and have not dieted as instructed before the
dose.
If you take large doses (5-20 grams or more daily) of Vitamin C as a routine before
you start LDA, you should taper it down to 3 grams or less during the 2 weeks prior to
LDA therapy. Do not stop it abruptly, or you'll likely have withdrawal symptoms.
Drugs Often Interact with LDA
No drugs, vitamins or herbs, except as listed in this booklet or specifically given to
you as part of an LDA prep or bowel protocol, or those you specifically discuss with the
26
doctor, should be taken the day before, the day of or the day after LDA. This applies to
everyone who receives LDA unless specifically advised by your physician.
Food Guidance for Patients with Moderate to Severe Food Allergy or Intolerance
At the time LDA is given to some patients, and up to three weeks afterwards, doses
of allergen from a food that has been eaten may cause increased sensitivity to that food.
And since many food allergens cross-react, exposure to the wrong foods, certainly during
the 3 critical days, but especially in the three weeks after LDA (as the lymphocytes are
maturing), may be harmful. Patients have sensitized to a wide variety of other foods,
pollens and molds when they have done this. Dr. McEwen very carefully selected the
foods for the LDA diet to avoid cross-sensitization to multiple allergens.
Therefore, you should definitely avoid the foods to which you know you are
intolerant or allergic (foods that have caused symptoms any time you’ve eaten them in the
past) for the three-week period after LDA. If you have severe food problems, the doctor
or one of the staff may discuss a different elimination diet you should follow before and
after the 3 critical days of LDA. The doctor may combine one or two diets for you to
follow at this time.
It has remains the policy in our office that all patients with other than simple hay
fever must follow the Basic LDA Diet. The exception is the select group of children with
autism, who simply cannot do the LDA diet with any success. Your doctor may have
another policy.
We now know from experience that LDA will always fail for eczema of
any variety, anaphylaxis, hives, angioedema (swelling of the mouth or lips) if
the LDA diet is not followed.
Significantly autistic children, generally speaking, will only eat specific foods and
nothing else. They’d literally rather starve. In these instances, the benefits of LDA likely
considerably outweigh the potential harm of not following the diet. In those instances,
I’ve always given LDA anyway, no matter what these kids may be eating. The treatment
has appeared to work. If the treatment fails, at least we’ve tried. There are a few LDA
Physicians who do this.
In recent years, I’ve heard of adults not following the LDA diet and doing well.
There will be more discussion about this, since certainly LDA would be much easier
without having to “do the diet”. My advice to most patients is that they should follow the
diet strictly for the first several LDA treatments, if they have food problems. Later on, it
might be OK to try to add a few foods to the diet. If you try this, be aware that your LDA
may not work as well, and you will need to switch back to following the diet.
27
Fasting
The LDA diet contains every food that has been shown to be safe with LDA.
However, some extremely food-intolerant patients are sensitive to some or all of the
foods on the diet. These patients have no choice but to fast for 24 hours before and 24
hours after LDA for the first few injections. Once LDA enhances food tolerance, patients
who have had to fast are usually able to eat at least some of the LDA Diet foods. I have
not seen problems with fasting, and I recommend it on the day of LDA for all adult
patients who don't tolerate the foods on the LDA diet.
After the LDA Diet
Most patients with food sensitivities must simply avoid the foods to which they know
they are allergic or intolerant as much as possible for the three weeks after LDA. This
does not mean foods that may just have been positive as a result of a blood test, and the
patient has never physically tested (challenged after a 6-7 day elimination) - only foods
that are known to cause symptoms when eaten.
If you don't have major food problems, you may begin adding regular foods after the
critical three days. However, if you do have severe food problems, for the next 5 days
after the 3-day LDA Diet, it is best to count the LDA Diet foods as safe and then add
small amounts of a wide variety of "rare" foods, preferably ones which have not generally
caused you to have symptoms in the past, or foods you have rarely or never eaten.
The amounts of added foods can be increased over the next week. After that time,
regular foods may be added back and should be tolerated much more easily. Very few
patients must resort to this. As time goes on, the necessity for avoidance of foods
lessens. The doctor or staff will advise you how to do this, if it is necessary.
Reminder: all patients must avoid alcohol for 10 days after LDA.
Unmasking, Rotation Diets and the Very Mixed Diet
The primary side effect of LDA for patients with food sensitivity may be
“unmasking”. With LDA immunotherapy, things you think you know about your foods,
both "safe" and "unsafe," may change. Many patients with significant food sensitivity
are allergic or intolerant to most of the foods they eat every day, but these foods are
“masked”. They usually cause minor symptoms, up and down, but patients don’t
attribute their symptoms to any particular food(s).
After one to three LDA injections (most often after 2-3), this food tolerance curve
may shift. Then foods that you had previously eaten in large quantities (perhaps even in
rotation) will sometimes make you ill if you attempt to eat the same quantity (or even
28
less) of those foods as you have in the past during the 3-4 weeks after LDA. This is called
"unmasking", and LDA can cause it to happen. Likewise, foods that made you ill before
LDA in very small quantities should become more tolerable as time goes on. This
confuses people who have been on rotation, but is a natural progression of LDA.
Patients who unmask to foods may complain that they have "lost" foods or have
"become sensitive" to foods after two to three LDA injections, because of this shift of the
food tolerance curve. This almost always stops occurring to any major degree after about
the 6th injection. When it does happen, it generally occurs for one to three injections,
and symptoms can last for one to four weeks.
Although this type of problem is not extremely common, the best suggestion to deal
with unmasking caused by LDA is the Very Mixed Diet (VMD). This consists of eating
very small quantities of multiple foods, usually on a daily basis. Your physician's office
may have copies of the VMD booklet. If not, it is available from the author, Nikki
Dumke, at Allergy Adapt, 1877 Polk Ave., Louisville, CO, 80027 (www.foodallergy.
org). Here, even rotation will often fail.
You should know that if you persist in eating large quantities of your previously
"safe" foods that begin to cause you to have symptoms after a few injections of LDA, you
will likely continue to have symptoms. This will often delay or destroy the desensitization
to those foods that LDA would normally produce. You may have to change your diet and
your thinking temporarily. If this should happen, I can assure you that this will go away,
but the longer you do it, and the larger quantities of these foods you eat, the longer it will
last.
So some patients who experience unmasking may need to vary the diet with large
varieties and much smaller quantities of low-allergenicity foods, usually with the second
or third LDA injections, and sometimes longer, during the three weeks after LDA. You
need to try to do this early in therapy if previously tolerated foods suddenly began
making you ill -- sometimes for 3 to 4 weeks after an injection. The need to do this
diminishes with further injections.
We advise our patients with severe food intolerance or allergy who experience
unmasking with LDA to eat very tiny quantities (tsp. to Tbsp. amounts at each meal) of a
wide variety of low-allergenicity foods, or of foods they seem to tolerate. Since patients
then are not able to rotate on a 4-5-day basis (because they “use up” their tolerable foods
quickly), they then may not be able to rotate foods at all during this time.
Fortunately, this issue of unmasking is ultimately self-correcting, and the need to do
either diet is rare and always temporary. The usual is for three to four weeks after their
29
second and/or third treatment, and lessening up to the first 6 treatments. Rarely,
unmasking may begin after the first LDA treatment.
However, you should get away from the idea of eating “mono” diets or large
quantities of foods in rotation. Remember, after even one LDA injection, your food
tolerance begins shifting, and some patients complain that they've lost many of the foods
which were previously safe for them to eat. Again, stick with the program, do your best
to make it work, and LDA should come through for you quite well indeed.
It's critical to remember that if you should have an adverse reaction to one of the first
few LDA injections, YOU SHOULD NOT STOP LDA. The doctor should be able to
figure out the problem and treat it appropriately for your next treatment.
As LDA gains effect with additional treatments, you should be able to eat larger
quantities of most all varieties of foods. If you had to rotate foods before you began
LDA treatment, rotation should become less and less necessary. Remember, rotation - if
you eat large quantities of single foods - could interfere with LDA and make you ill.
Food Idiosyncrasies
For most patients, after six to eight injections or so, the full effects of LDA may not
begin until about three to four weeks after the shot. In the 3 weeks preceding that, you
may be upset by foods that will be safe after that three-week period. Also, in the first
week or two, you may feel you experience odd symptoms after LDA. Don't assume your
symptoms are necessarily being caused by the diet you are eating after LDA, since
patients can experience almost any symptoms conceivable while the T-cells are maturing.
These odd symptoms may occur after almost any injection, even if you've had a dozen or
so. They are temporary.
Boosting Tolerance
We advise all of you, after three LDA treatments, to begin adding small amounts of
foods to which you were previously significantly sensitive. Adding these foods,
beginning 3 weeks after LDA, will encourage tolerance. If you have a significant
reaction to a particular food, wait until the next shot to challenge that food only, but you
may try other foods that may result in a better response. If you continue to avoid these
foods, you may never desensitize to them

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