Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring

INTRODUCTION

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'.)

TECHNICAL ISSUES

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 [3], 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 [2]. 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 the venoms to which the patient showed skin test sensitivity.

                         

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Oct 2014. | This topic last updated: Aug 28, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. Graft DF. Insect sting allergy. Med Clin North Am 2006; 90:211.
  2. Golden DBK. Insect allergy. In: Middleton's allergy: Principles and practice, 7th ed, Adkinson NF, Bochner BS, Busse WW, et aL (Eds), Mosby, Philadelphia 2009. p.1005.
  3. Finegold I. Issues in stinging insect allergy immunotherapy: a review. Curr Opin Allergy Clin Immunol 2008; 8:343.
  4. Reisman RE, Livingston A. Venom immunotherapy: 10 years of experience with administration of single venoms and 50 micrograms maintenance doses. J Allergy Clin Immunol 1992; 89:1189.
  5. Brockow K, Kiehn M, Riethmüller C, et al. Efficacy of antihistamine pretreatment in the prevention of adverse reactions to Hymenoptera immunotherapy: a prospective, randomized, placebo-controlled trial. J Allergy Clin Immunol 1997; 100:458.
  6. Müller U, Hari Y, Berchtold E. Premedication with antihistamines may enhance efficacy of specific-allergen immunotherapy. J Allergy Clin Immunol 2001; 107:81.
  7. Wöhrl S, Gamper S, Hemmer W, et al. Premedication with montelukast reduces local reactions of allergen immunotherapy. Int Arch Allergy Immunol 2007; 144:137.
  8. Ruëff F, Przybilla B, Biló MB, et al. Predictors of side effects during the buildup phase of venom immunotherapy for Hymenoptera venom allergy: the importance of baseline serum tryptase. J Allergy Clin Immunol 2010; 126:105.
  9. Ruëff F, Przybilla B, Biló MB, et al. Predictors of severe systemic anaphylactic reactions in patients with Hymenoptera venom allergy: importance of baseline serum tryptase-a study of the European Academy of Allergology and Clinical Immunology Interest Group on Insect Venom Hypersensitivity. J Allergy Clin Immunol 2009; 124:1047.
  10. Haeberli G, Brönnimann M, Hunziker T, Müller U. Elevated basal serum tryptase and hymenoptera venom allergy: relation to severity of sting reactions and to safety and efficacy of venom immunotherapy. Clin Exp Allergy 2003; 33:1216.
  11. Roumana A, Pitsios C, Vartholomaios S, et al. The safety of initiating Hymenoptera immunotherapy at 1 microg of venom extract. J Allergy Clin Immunol 2009; 124:379.
  12. Golden DB, Valentine MD, Kagey-Sobotka A, Lichtenstein LM. Regimens of Hymenoptera venom immunotherapy. Ann Intern Med 1980; 92:620.
  13. Golden DBK, Kagey-Sobotka A, Hamilton RG. Human immune response to Hymenoptera venoms. J Allergy Clin Immunol 1983; 71:140 (Abstract).
  14. Graft DF, Schuberth KC, Kagey-Sobotka A. Immunologic effects of prolonged venom immunotherapy in children. J Allergy Clin Immunol 1983; 71:140 (Abstract).
  15. Houliston L, Nolan R, Noble V, et al. Honeybee venom immunotherapy in children using a 50-μg maintenance dose. J Allergy Clin Immunol 2011; 127:98.
  16. Konstantinou GN, Manoussakis E, Douladiris N, et al. A 5-year venom immunotherapy protocol with 50 μg maintenance dose: safety and efficacy in school children. Pediatr Allergy Immunol 2011; 22:393.
  17. Muller UR. Insect sting allergy: Clinical picture, diagnosis, and treatment, Gustav Fischer Verlag, Germany 1990. p.130.
  18. Goldberg A, Yogev A, Confino-Cohen R. Three days rush venom immunotherapy in bee allergy: safe, inexpensive and instantaneously effective. Int Arch Allergy Immunol 2011; 156:90.
  19. Bernstein JA, Kagen SL, Bernstein DI, Bernstein IL. Rapid venom immunotherapy is safe for routine use in the treatment of patients with Hymenoptera anaphylaxis. Ann Allergy 1994; 73:423.
  20. Thurnheer U, Müller U, Stoller R, et al. Venom immunotherapy in hymenoptera sting allergy. Comparison of rush and conventional hyposensitization and observations during long-term treatment. Allergy 1983; 38:465.
  21. Bernstein J, personal communication.
  22. Brehler R, Wolf H, Kütting B, et al. Safety of a two-day ultrarush insect venom immunotherapy protocol in comparison with protocols of longer duration and involving a larger number of injections. J Allergy Clin Immunol 2000; 105:1231.
  23. Golden DB, Moffitt J, Nicklas RA, et al. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011; 127:852.
  24. Bonifazi F, Jutel M, Biló BM, et al. Prevention and treatment of hymenoptera venom allergy: guidelines for clinical practice. Allergy 2005; 60:1459.
  25. Goldberg A, Confino-Cohen R. Maintenance venom immunotherapy administered at 3-month intervals is both safe and efficacious. J Allergy Clin Immunol 2001; 107:902.
  26. Simioni L, Vianello A, Bonadonna P, et al. Efficacy of venom immunotherapy given every 3 or 4 months: a prospective comparison with the conventional regimen. Ann Allergy Asthma Immunol 2013; 110:51.
  27. Goldberg A, Confino-Cohen R. Effectiveness of maintenance bee venom immunotherapy administered at 6-month intervals. Ann Allergy Asthma Immunol 2007; 99:352.
  28. Lockey RF, Turkeltaub PC, Olive ES, et al. The Hymenoptera venom study. III: Safety of venom immunotherapy. J Allergy Clin Immunol 1990; 86:775.
  29. Van Metre TE Jr, Adkinson NF Jr, Amodio FJ, et al. A comparison of immunotherapy schedules for injection treatment of ragweed pollen hay fever. J Allergy Clin Immunol 1982; 69:181.
  30. Goldberg A, Confino-Cohen R. Rush venom immunotherapy in patients experiencing recurrent systemic reactions to conventional venom immunotherapy. Ann Allergy Asthma Immunol 2003; 91:405.
  31. Galera C, Soohun N, Zankar N, et al. Severe anaphylaxis to bee venom immunotherapy: efficacy of pretreatment and concurrent treatment with omalizumab. J Investig Allergol Clin Immunol 2009; 19:225.
  32. Schulze J, Rose M, Zielen S. Beekeepers anaphylaxis: successful immunotherapy covered by omalizumab. Allergy 2007; 62:963.
  33. Nakonechna A, Abuzakouk M. Human albumin causes anaphylaxis during bee venom immunotherapy. Ann Allergy Asthma Immunol 2014; 112:559.
  34. Golden D, Graft D, unpublished observations from personal practice experience.
  35. Hunt KJ, Valentine MD, Sobotka AK, et al. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978; 299:157.
  36. Golden DB, Lawrence ID, Hamilton RH, et al. Clinical correlation of the venom-specific IgG antibody level during maintenance venom immunotherapy. J Allergy Clin Immunol 1992; 90:386.
  37. Reisman RE. Should routine measurements of serum venom-specific IgG be a standard of practice in patients receiving venom immunotherapy? J Allergy Clin Immunol 1992; 90:282.
  38. Graft DF, Schuberth KC, Kagey-Sobotka A, et al. The development of negative skin tests in children treated with venom immunotherapy. J Allergy Clin Immunol 1984; 73:61.
  39. Golden DB, Kwiterovich KA, Kagey-Sobotka A, et al. Discontinuing venom immunotherapy: outcome after five years. J Allergy Clin Immunol 1996; 97:579.
  40. Franken HH, Dubois AE, Minkema HJ, et al. Lack of reproducibility of a single negative sting challenge response in the assessment of anaphylactic risk in patients with suspected yellow jacket hypersensitivity. J Allergy Clin Immunol 1994; 93:431.
  41. Fricker M, Helbling A, Schwartz L, Müller U. Hymenoptera sting anaphylaxis and urticaria pigmentosa: clinical findings and results of venom immunotherapy in ten patients. J Allergy Clin Immunol 1997; 100:11.
  42. González de Olano D, Alvarez-Twose I, Esteban-López MI, et al. Safety and effectiveness of immunotherapy in patients with indolent systemic mastocytosis presenting with Hymenoptera venom anaphylaxis. J Allergy Clin Immunol 2008; 121:519.
  43. Ruëff F, Wenderoth A, Przybilla B. Patients still reacting to a sting challenge while receiving conventional Hymenoptera venom immunotherapy are protected by increased venom doses. J Allergy Clin Immunol 2001; 108:1027.
  44. Keating MU, Kagey-Sobotka A, Hamilton RG, Yunginger JW. Clinical and immunologic follow-up of patients who stop venom immunotherapy. J Allergy Clin Immunol 1991; 88:339.
  45. Committee on Insects. The discontinuation of Hymenoptera venom immunotherapy. J Allergy Clin Immunol 1998; 101:573.
  46. Lerch E, Müller UR. Long-term protection after stopping venom immunotherapy: results of re-stings in 200 patients. J Allergy Clin Immunol 1998; 101:606.