Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring
- 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]. Venom immunotherapy (VIT) is highly effective and well-tolerated by most patients.
VIT for patients with allergies to honey bee, yellow jacket, yellow hornet, white-faced hornet, and wasp is administered using purified venoms, whereas whole body extracts are used in immunotherapy for fire ant allergy. The techniques, adverse effects, and safety of VIT will be reviewed here. Efficacy, indications, and mechanism of action of VIT, as well as immunotherapy for fire ant allergy, are discussed elsewhere. (See "Hymenoptera venom immunotherapy: Efficacy, indications, and mechanism of action" and "Stings of imported fire ants: Clinical manifestations, diagnosis, and treatment", section on 'Treatment'.)
Issues in the administration of VIT include venom selection, dosing, injection protocol, premedications, and adverse effects.
Venom selection — The venoms used for immunotherapy are the same as those used for skin testing. In the United States, there are two companies that supply venom extracts for skin testing and treatment: Hollister-Stier Laboratories (Spokane, Washington) and ALK-Abelló (Round Rock, Texas). Depot preparations are available in some countries , although not in the United States. The discussion herein does not apply to depot products.
Multiple versus single venom — In the United States, patients are usually treated with all of the venoms to which they had a positive skin test, with the goal of providing maximal coverage for future sting events . This approach ensures that a patient who has reacted to a yellow jacket sting, for example, is not left with doubts about the expected outcome of a sting from a different Hymenoptera insect (to which he/she had a positive venom skin test but had never been stung, such as a honey bee). Thus, skin testing should be performed with venoms from each of the insects relevant to the geographic area, and treatment should include all of the venoms to which the patient showed skin test sensitivity.
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- TECHNICAL ISSUES
- Venom selection
- - Multiple versus single venom
- Measurement of baseline tryptase
- Other precautions
- - Alterations in venom extracts
- - Initial
- - Maintenance
- Choice of protocol
- - Traditional protocols
- - Accelerated protocols
- Interval between maintenance injections
- ADVERSE EFFECTS AND SAFETY OF VIT
- Systemic reactions to VIT
- Recurrent systemic reactions to VIT
- Local reactions
- Long-term safety
- MONITORING VIT
- Assessing effectiveness
- - Venom-specific IgG
- - Venom-specific IgE
- - Venom skin tests
- - Sting challenges
- Treatment failure
- Duration of therapy
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS