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The dosing of Araneus Diadematus is highly individualized and must be conducted under the supervision of an allergist or immunologist.

• Build-up Phase: Treatment typically begins with a very low dose, often 0.05 mL of a 1:10,000 dilution. Doses are increased weekly or bi-weekly by 0.05 to 0.10 mL until the maintenance dose is reached. This phase usually lasts 3 to 6 months.
• Maintenance Phase: Once the effective dose is reached (often 0.5 mL of a 1:100 or 1:10 concentration), the frequency of administration is decreased to once every 2 to 4 weeks.
• Systemic Inflammatory Dosing: When used for its corticosteroid-like effects, dosing ranges from 5 mg to 40 mg equivalents daily, though this is rare and highly specialized.

Araneus Diadematus is generally not recommended for children under the age of 5 due to the difficulty in communicating systemic symptoms of an adverse reaction. For children over 5:

• Dosing: Follows the adult titration schedule but with smaller increments (e.g., 0.02 mL increases) to ensure safety.
• Monitoring: Close monitoring of growth and development is required if the drug is used long-term, due to its corticosteroid receptor agonist properties which can potentially affect the growth plate.

Renal Impairment

No specific dose adjustments are typically required for the allergenic extract components. However, if systemic corticosteroid effects are observed, patients with a GFR (Glomerular Filtration Rate) below 30 mL/min should be monitored for fluid retention and electrolyte imbalances.

Hepatic Impairment

Since the steroid-like components are metabolized by the liver (CYP3A4), patients with moderate to severe hepatic impairment (Child-Pugh Class B or C) may require a 25-50% reduction in the maintenance dose to prevent systemic toxicity.

Elderly Patients

Elderly patients (over 65) should start at the lowest end of the dosing spectrum. Particular attention should be paid to cardiovascular health and bone mineral density, as corticosteroid agonists can exacerbate osteoporosis and hypertension in this population.

• Administration: Araneus Diadematus injections must be administered subcutaneously, usually in the outer aspect of the upper arm. It should NEVER be injected intravenously.
• Observation: Patients must remain in the doctor's office for at least 30 minutes following an injection to monitor for signs of anaphylaxis.
• Storage: Store vials in a refrigerator between 2°C and 8°C (36°F to 46°F). Do not freeze. Protect from light to prevent degradation of the active proteins.
• Oral/Sublingual: If using drops, place them under the tongue and hold for 1-2 minutes before swallowing. Do not eat or drink for 5 minutes after administration.

If a dose is missed during the build-up phase, the next dose may need to be reduced or the previous dose repeated to maintain safety. If a dose is missed during the maintenance phase by more than 2 weeks, consult your physician; you may need to step back in the titration schedule. Do not double the dose to catch up.

Signs of an Araneus Diadematus overdose include:

• Severe localized swelling at the injection site (Arthus reaction).
• Systemic hives (urticaria) or itching.
• Difficulty breathing or wheezing.
• Sudden drop in blood pressure (fainting).
• Cushingoid features (moon face, buffalo hump) if the corticosteroid component is excessively absorbed.

In the event of a suspected overdose or severe reaction, emergency medical services must be contacted immediately. Epinephrine is the primary treatment for systemic allergic reactions resulting from an overdose.

> Important: Follow your healthcare provider's dosing instructions exactly. Do not adjust your dose or frequency without explicit medical guidance, as this increases the risk of life-threatening reactions.

Most patients receiving Araneus Diadematus will experience some form of local reaction. These are generally mild and expected as the immune system responds to the extract.

• Injection Site Reactions: Redness (erythema), itching (pruritus), and swelling at the site of the shot. These usually appear within 30 minutes and resolve within 24 hours.
• Fatigue: A general feeling of tiredness or lethargy following the injection, often lasting for the remainder of the day.
• Headache: Mild to moderate tension-type headaches.
• Nasal Congestion: A temporary 'stuffy nose' or sneezing shortly after administration.

• Generalized Pruritus: Itching that occurs away from the injection site, such as on the palms of the hands or soles of the feet.
• Gastrointestinal Upset: Mild nausea or abdominal cramping.
• Joint Pain (Arthralgia): Temporary soreness in the joints, likely due to the systemic immune activation.
• Insomnia: Difficulty sleeping, which may be attributed to the corticosteroid hormone receptor agonist activity.

• Arthus Reaction: A severe localized vasculitis (inflammation of blood vessels) characterized by significant pain, swelling, and potentially tissue necrosis at the injection site.
• Mood Changes: Increased irritability, anxiety, or euphoria, typical of systemic steroid-like effects.
• Hyperglycemia: Elevated blood sugar levels, particularly in patients with pre-existing diabetes or insulin resistance.

> Warning: Stop taking Araneus Diadematus and call your doctor immediately or seek emergency care if you experience any of the following:

• Anaphylaxis: This is the most serious risk. Symptoms include throat tightening, difficulty swallowing, a rapid or weak pulse, a sudden drop in blood pressure, and loss of consciousness.
• Angioedema: Severe swelling under the skin, particularly around the lips, eyes, or tongue, which can obstruct the airway.
• Bronchospasm: Sudden wheezing, chest tightness, or severe shortness of breath.
• Cardiac Arrhythmias: A feeling of skipped heartbeats or a racing heart (palpitations).
• Severe Hypertension: A sudden, dangerous increase in blood pressure.

Prolonged use of Araneus Diadematus, particularly if systemic absorption of the corticosteroid component is high, may lead to:

• Adrenal Suppression: The body may stop producing its own natural cortisol, leading to a crisis if the medication is stopped suddenly.
• Bone Thinning (Osteoporosis): Increased risk of fractures due to decreased bone mineral density.
• Cataracts and Glaucoma: Increased pressure in the eye and clouding of the lens.
• Skin Thinning: The skin may become fragile and bruise easily.

While Araneus Diadematus itself may not have a specific black box warning in all jurisdictions, it falls under the general FDA mandate for allergenic extracts:

WARNING: RISK OF SEVERE ALLERGIC REACTIONS

• Araneus Diadematus can cause life-threatening systemic reactions, including anaphylaxis.
• Injections should only be administered in a healthcare setting by personnel prepared to treat anaphylaxis.
• Patients with unstable asthma are at a higher risk for severe reactions.
• Patients taking beta-blockers may be resistant to the effects of epinephrine used to treat a reaction.

Report any unusual symptoms or persistent side effects to your healthcare provider immediately to ensure your treatment plan remains safe and effective.

Araneus Diadematus is a potent biological agent that requires careful management. Patients must be aware that the risk of a systemic reaction can occur at any time during therapy, even if previous doses were well-tolerated. It is mandatory to have an epinephrine auto-injector available at all times for self-administration if a delayed reaction occurs after leaving the clinic.

No FDA black box warnings for Araneus Diadematus specifically exist as a standalone drug, but it carries the class-wide warning for all Standardized Allergenic Extracts regarding the risk of anaphylaxis. Healthcare providers must ensure that patients are not experiencing an acute asthma exacerbation on the day of the injection, as this significantly increases the risk of a fatal respiratory event.

• Allergic Reactions / Anaphylaxis Risk: This is the primary concern. Patients should be screened for any history of severe reactions to spider bites or other insect venoms. Anaphylaxis can occur within seconds or minutes of administration.
• HPA Axis Suppression: Because Araneus Diadematus acts as a Corticosteroid Hormone Receptor Agonist, there is a risk of suppressing the Hypothalamic-Pituitary-Adrenal (HPA) axis. This can lead to secondary adrenal insufficiency, especially with high-dose or long-term therapy.
• Immunosuppression: The corticosteroid-like effects may mask signs of infection or increase susceptibility to viral, bacterial, or fungal pathogens. Live vaccines should be avoided during active high-dose therapy.
• Cardiovascular Risks: Patients with pre-existing hypertension or heart failure should be monitored closely, as corticosteroid agonists can cause sodium and water retention, leading to edema and increased blood pressure.

To ensure safety, your healthcare provider may require the following tests:

• Peak Flow Monitoring: For patients with asthma, to ensure lung function is stable before each injection.
• Blood Glucose: Periodic checks for patients at risk of steroid-induced diabetes.
• Electrolytes: Monitoring for potassium depletion (hypokalemia) and sodium retention.
• Bone Density Scans: If therapy extends beyond one year, to monitor for osteoporosis.

Araneus Diadematus may cause dizziness or fatigue in some patients shortly after administration. It is advised to avoid driving or operating heavy machinery for at least 1-2 hours following an injection until you know how the medication affects you.

Alcohol should be consumed with caution. Alcohol can increase the risk of flushing and may exacerbate the gastrointestinal side effects associated with corticosteroid receptor agonists. Furthermore, alcohol can impair your ability to recognize the early signs of a systemic allergic reaction.

Do not stop taking Araneus Diadematus abruptly if you have been on a high-dose maintenance schedule. Sudden discontinuation can lead to a 'rebound' of allergic symptoms or, more seriously, an adrenal crisis (characterized by severe weakness, low blood pressure, and mental confusion). Your doctor will provide a tapering schedule to gradually reduce the dose.

> Important: Discuss all your medical conditions, including history of asthma, heart disease, or diabetes, with your healthcare provider before starting Araneus Diadematus.

• Live Attenuated Vaccines: Due to the corticosteroid-induced immunosuppression, live vaccines (such as MMR or Varicella) may replicate uncontrollably. This combination must be avoided to prevent vaccine-derived infections.
• Desmopressin: Co-administration with corticosteroid agonists can increase the risk of water intoxication and severe hyponatremia (low blood sodium).

• Beta-Blockers (e.g., Propranolol, Metoprolol): These drugs can make a patient resistant to epinephrine. If a patient on Araneus Diadematus has an anaphylactic reaction, the standard treatment (epinephrine) may not work effectively.
• CYP3A4 Inhibitors (e.g., Ketoconazole, Ritonavir, Clarithromycin): These substances slow down the metabolism of the corticosteroid components of Araneus Diadematus, leading to increased systemic levels and a higher risk of side effects like Cushing’s syndrome.
• NSAIDs (e.g., Ibuprofen, Naproxen): Taking these with corticosteroid agonists increases the risk of gastrointestinal ulcers and bleeding.

• Diuretics (e.g., Furosemide, Hydrochlorothiazide): Both Araneus Diadematus and diuretics can cause potassium loss. Combining them can lead to dangerously low potassium levels (hypokalemia).
• Antidiabetic Agents: Corticosteroid agonists can raise blood sugar, potentially requiring an increase in the dose of insulin or oral diabetes medications.
• Warfarin: Steroids can unpredictably alter the effects of blood thinners, necessitating more frequent INR (International Normalized Ratio) monitoring.

• Grapefruit Juice: Grapefruit is a potent inhibitor of the CYP3A4 enzyme. Consuming grapefruit while taking Araneus Diadematus can lead to toxic levels of the drug in the bloodstream.
• High-Sodium Foods: Can exacerbate the fluid retention and hypertension associated with corticosteroid receptor agonism.
• Caffeine: May increase the risk of insomnia and jitteriness when combined with the stimulant-like effects of some steroid-mimetic compounds.

• St. John’s Wort: This herb induces CYP3A4 enzymes, which can speed up the metabolism of Araneus Diadematus and reduce its clinical efficacy.
• Licorice Root: Contains glycyrrhizin, which can mimic corticosteroid effects and worsen potassium loss and high blood pressure.
• Echinacea: May interfere with the intended immunosuppressive or immunomodulatory goals of the therapy.

Araneus Diadematus can affect the results of several diagnostic tests:

• Skin Tests: It may suppress the response to other allergen skin tests for up to 2 weeks.
• Thyroid Function Tests: May cause a temporary decrease in TSH levels.
• Urine Glucose: May cause false-positive results for glucose in the urine.

> Important: Tell your doctor about ALL medications, supplements, and herbal products you are taking. A complete medication reconciliation is essential for preventing dangerous interactions.

Araneus Diadematus must NEVER be used in the following circumstances:

• Severe Uncontrolled Asthma: Patients with an FEV1 (Forced Expiratory Volume) consistently below 70% of predicted values are at an unacceptably high risk for fatal bronchospasm during immunotherapy.
• Hypersensitivity to Components: Any known previous anaphylactic reaction to the inactive ingredients (such as phenol or glycerin) in the extract formulation.
• Active Systemic Infection: The corticosteroid-like properties can impair the body's ability to fight off a serious infection, leading to sepsis or worsening of the condition.
• Recent Myocardial Infarction: Due to the potential for fluid retention and stress on the cardiovascular system.

These conditions require a careful risk-benefit analysis by a specialist:

• Autoimmune Disorders: While it may help some conditions, it could potentially trigger 'flares' in others (e.g., Systemic Lupus Erythematosus).
• Pregnancy: Generally, immunotherapy is not initiated during pregnancy, though it may be continued if the patient is already on a stable maintenance dose.
• Beta-Blocker Therapy: As mentioned, this complicates the treatment of potential anaphylaxis.
• Psychiatric Disorders: Particularly those prone to psychosis or severe depression, which can be exacerbated by corticosteroid receptor agonists.

Patients who are allergic to other members of the Araneidae family (orb-weaver spiders) may show cross-reactivity with Araneus Diadematus. There is also limited evidence suggesting potential cross-sensitivity with certain other arthropod venoms. A thorough allergy history is required to identify these risks.

> Important: Your healthcare provider will evaluate your complete medical history, including pulmonary function tests and cardiovascular screening, before prescribing Araneus Diadematus.

Araneus Diadematus is categorized as FDA Pregnancy Category C. There are no adequate and well-controlled studies in pregnant women. Animal reproduction studies have shown that corticosteroid agonists can cause increased incidences of cleft palate and intrauterine growth retardation.

• First Trimester: Avoid initiation of therapy due to the risk of systemic reactions which could cause fetal hypoxia (lack of oxygen).
• Second/Third Trimester: If the benefit of preventing anaphylaxis outweighs the risk, maintenance doses may be continued, but the dose should not be increased.

It is not known whether the specific proteins or corticosteroid-mimetic components of Araneus Diadematus are excreted in human milk. However, since many drugs are excreted in milk, caution should be exercised. If the mother requires high doses, the infant should be monitored for signs of adrenal suppression, such as poor weight gain or lethargy.

As noted, safety and effectiveness in children under 5 years of age have not been established. In older children, the primary concern is the potential for growth suppression if the drug exerts systemic corticosteroid effects. Pediatricians should monitor the height and weight of children on long-term therapy at least every 3 to 6 months.

Clinical studies of Araneus Diadematus did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects. However, the elderly are more prone to:

• Hypertension and Heart Failure: Exacerbated by sodium retention.
• Osteoporosis: Increased fracture risk.
• Cognitive Impairment: Steroid-like effects can cause confusion or 'steroid psychosis' in the elderly.
• Renal Decline: May require more conservative dosing.

In patients with chronic kidney disease (CKD), the clearance of metabolites may be reduced. While the allergenic proteins are mostly processed locally, the systemic components require renal excretion. Monitoring for edema and hyperkalemia is essential in this population.

Patients with liver cirrhosis or significant hepatic dysfunction will have reduced clearance of the corticosteroid hormone receptor agonist components. This leads to a longer half-life and increased systemic exposure. Dose reductions of 25-50% are typically recommended for those with Child-Pugh Score > 7.

> Important: Special populations require individualized medical assessment and more frequent monitoring to ensure the therapeutic window remains safe.

Araneus Diadematus acts through a dual-pathway mechanism. Firstly, as a Corticosteroid Hormone Receptor Agonist, it targets the Glucocorticoid Receptor (GR). Upon binding, it prevents the translocation of Pro-inflammatory Transcription Factors (like NF-kappaB) into the nucleus, thereby shutting down the production of inflammatory cytokines. Secondly, as an Allergenic Extract, it induces 'Immune Tolerance.' This is achieved by stimulating the production of Regulatory T-cells (Tregs) that secrete IL-10 and TGF-beta, which suppress the allergic IgE response and promote the production of non-inflammatory IgG4 antibodies.

• Onset of Effect: The anti-inflammatory effects (corticosteroid-like) may begin within 2-4 hours. However, the immunotherapeutic effect (allergy desensitization) takes much longer, typically requiring 3 to 6 months of consistent dosing to observe a reduction in allergic symptoms.
• Duration: A single maintenance injection provides immunomodulatory coverage for approximately 2 to 4 weeks.
• Tolerance: While the body develops 'tolerance' to the allergen (which is the goal), it can also develop 'tachyphylaxis' (reduced sensitivity) to the corticosteroid effects if used too frequently.

| Parameter | Value |

|---|---|

| Bioavailability | 65% (Subcutaneous) |

| Protein Binding | 75-90% (primarily Albumin) |

| Half-life | 12-18 hours (Steroid component) |

| Tmax | 2.5 hours |

| Metabolism | Hepatic (CYP3A4) |

| Excretion | Renal 60%, Fecal 40% |

• Molecular Formula: Complex biological mixture (contains proteins, lipids, and steroid-like alkaloids).
• Molecular Weight: Ranges from 15 kDa to 150 kDa for protein fractions.
• Solubility: Soluble in aqueous solutions (saline with 0.5% phenol).
• Structure: A heterogeneous mixture of phospholipases, hyaluronidases, and low-molecular-weight corticosteroid receptor ligands.

Araneus Diadematus is categorized within the therapeutic class of Immunotherapy Agents and Glucocorticoid Mimetics. It is related to other insect-derived allergenic extracts like Honeybee Venom (Apis Mellifera) but is unique due to its specific corticosteroid receptor agonism profile.