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 honeybee, 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 venom immunotherapy (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 Labs (Spokane, Washington) and ALK-Abello Labs (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 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 had a positive venom skin test but had never been stung, such as honeybee). Thus, skin testing should be performed with venoms from each of the insects relevant to the geographic area, and treatment should include all the venoms to which the patient showed skin test sensitivity.