Hymenoptera venom immunotherapy: Efficacy, indications, and mechanism of action
- David F Graft, MD
David F Graft, MD
- Adjunct Professor of Family Medicine and Pediatrics
- University of Minnesota Medical School
Hymenoptera stings can result in life-threatening anaphylaxis, and the most severe reactions can be refractory to single or multiple doses of epinephrine [1,2]. Immunotherapy for venom allergy has been available for over four decades and is highly effective. Unfortunately, many patients with sting-induced allergic reactions are not referred to an allergist/immunologist for evaluation and are never offered this potentially lifesaving therapy .
The indications for treatment with venom immunotherapy (VIT) as well as patient selection, effectiveness, and mechanism of action will be reviewed here. Protocols and safety of VIT and the diagnosis of venom allergy are discussed separately. (See "Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring" and "Diagnosis of Hymenoptera venom allergy".)
NATURAL HISTORY OF SYSTEMIC ALLERGIC REACTIONS TO VENOM
A systemic allergic reaction to a sting involves signs and symptoms of immunoglobulin E (IgE)-mediated allergy distant from the site of the sting. In contrast, a local reaction consists of painful swelling and erythema limited to tissues contiguous with the site of the sting. Systemic allergic reactions may range from widespread hives and angioedema (ie, a cutaneous systemic reaction) to anaphylaxis (table 1). Although urticaria/angioedema are generally considered characteristic of an allergic reaction, the absence of urticaria or angioedema during anaphylaxis may be a risk factor for severe anaphylaxis .
An understanding of the natural history of venom allergy is critical to the determination of which patients should be treated with VIT. The natural history differs between adults and children (defined in studies as younger than 17 years of age), with adults being at greater overall risk for recurrent systemic reactions. The following generalizations can be made:
●In adult patients with past systemic reactions and evidence of venom-specific IgE, the risk of a systemic reaction to a subsequent sting is approximately 35 to 60 percent if VIT is not administered [1,5,6]. Patients with the most severe initial reactions have the highest risk of a recurrence. The variability in reaction rates may arise from differences in Hymenoptera species, the amount of venom delivered during a particular sting, whether the sting was sustained in-hospital or in the field, fluctuations in the patient's immunologic status, or other intrinsic and extrinsic factors .
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- NATURAL HISTORY OF SYSTEMIC ALLERGIC REACTIONS TO VENOM
- EFFECTIVENESS OF VIT
- Reduced risk of recurrent reactions
- Honey bee versus vespid VIT
- Quality of life
- INDICATIONS AND PATIENT SELECTION
- Patients with past systemic reactions
- - Adults
- - Children
- - Other considerations
- - Pregnant women
- Informed consent
- Patients requiring ACE inhibitors or beta-blockers
- Patients with large local reactions
- MECHANISM OF ACTION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS