Hymenoptera venom immunotherapy: Determining duration of therapy
- Jeffrey G Demain, MD, FAAAAI
Jeffrey G Demain, MD, FAAAAI
- Clinical Professor of Pediatrics
- University of Washington
Venom immunotherapy (VIT) is highly effective for the treatment of patients with systemic allergic reactions (SARs) to Hymenoptera venom. Overall, VIT reduces the chance of having a serious allergic reaction to an insect sting by 90 percent . Stated differently, more than 95 percent of patients allergic to vespid (ie, yellow jacket, hornet, and wasp) venom, and 80 to 90 percent of those allergic to honey bee venom will not develop any systemic allergic symptoms if re-stung while receiving VIT [2-8]. The rest usually experience only mild symptoms. VIT has also been demonstrated to significantly improve health-related quality of life [1,9-11].
This topic will review the studies that have addressed this question and discuss the risk factors for recurrent systemic reactions to Hymenoptera stings after the discontinuation of VIT. The efficacy, indications, and other issues concerning VIT are presented separately. (See "Hymenoptera venom immunotherapy: Efficacy, indications, and mechanism of action" and "Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring".)
DURATION OF TREATMENT
The risk of a recurrent systemic reaction to a sting after stopping venom immunotherapy (VIT) decreases the longer VIT has been administered . After three to five years of VIT, most patients who stop VIT will remain protected from recurrent systemic allergic reactions (SARs), and this is the suggested minimum duration of therapy. This recommendation is based upon the following studies:
●One year of treatment — An early retrospective study evaluated recurrent systemic reactions to stings in 82 patients who chose to stop VIT after varying amounts of time, with a mean duration of treatment of 14 months . Over the ensuing three to four years, 22 percent of those who were re-stung had SARs, compared with 1 to 3 percent of patients who remained on VIT. Thus, one year of VIT did not provide sufficient protection for nearly one-quarter of patients.
●At least three years of treatment — Several prospective studies evaluated the protection afforded by VIT if it was given for at least three years and then stopped (table 1) [14-20]. Of note, most of the patients in these early studies were selected because they showed evidence of a reduction in sensitivity to venom in response to VIT, either through skin tests or serum tests or because they had done well with a subsequent sting, so their prognosis may have been better as a group. After three years of VIT, 83 to 100 percent of patients remained protected against recurrent SARs in the first one to three years after stopping. Most or all of the patients who did develop SARs with repeat stings after stopping VIT had only mild symptoms.
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- DURATION OF TREATMENT
- RISK FACTORS FOR RECURRENT SARs OR POOR OUTCOMES
- Older age
- Severe pretreatment reaction
- Bee venom allergy
- Cardiovascular disease
- - Use of cardiovascular medications
- Reactions to injections or stings during VIT
- Extreme sensitivity on diagnostic testing
- Mast cell disorders
- Time since stopping therapy
- Repeated stings after stopping VIT
- DECIDING TO STOP THERAPY
- Candidates for indefinite therapy
- The role of testing
- COUNSELING THE PATIENT
- SUMMARY AND RECOMMENDATIONS