Rush and ultra-rush venom immunotherapy for Hymenoptera allergy
- Marc Serota, MD
Marc Serota, MD
- Associate Professor of Dermatology and Allergy
- Denver VA Medical Center and Denver University
- Jay M Portnoy, MD
Jay M Portnoy, MD
- Chief, Section of Allergy, Asthma and Immunology
- Children's Mercy Hospitals and Clinics
Venom immunotherapy (VIT) to treat systemic allergic reactions to winged Hymenoptera (hornets, yellow jackets, honey bees, and wasps) may be administered according to several different schedules. Accelerated schedules include "rush" and "ultra-rush."
This topic review will discuss the advantages and disadvantages of rush and ultra-rush schedules for VIT, indications for accelerated VIT, and provide several specific examples of protocols that have been used successfully. Conventional schedules for VIT are discussed separately. (See "Hymenoptera venom immunotherapy: Technical issues, protocols, adverse effects, and monitoring" and "Stings of imported fire ants: Clinical manifestations, diagnosis, and treatment".)
Terminology — All forms of subcutaneous immunotherapy (SCIT) are divided into two phases: build-up and maintenance.
●The build-up phase involves serial injections of increasing amounts of allergen. During this phase, tolerance to the allergen is gradually induced and the patient's immune response to the allergen is modified from a T helper type 2 (Th2) phenotype to a T helper type 1 (Th1) phenotype [1,2]. In conventional VIT schedules, the build-up phase involves one or three injections per week and extends from 8 to 21 weeks. Conventional schedules for VIT are shown in the tables (table 1 and table 2). Th2 and Th1 responses are reviewed separately. (See "T helper subsets: Differentiation and role in disease", section on 'Functional differences of T helper subsets'.)
●The maintenance phase of allergen immunotherapy involves ongoing injections of an immunizing dose of allergen, usually at intervals of three to six weeks. During the maintenance phase, the immune transformation becomes complete. This phase is usually extended for a period of three to five years because shorter durations of treatment are associated with higher rates of recurrent systemic allergic reactions to subsequent stings. (See "Hymenoptera venom immunotherapy: Determining duration of therapy", section on 'Duration of treatment'.)
- Larché M, Akdis CA, Valenta R. Immunological mechanisms of allergen-specific immunotherapy. Nat Rev Immunol 2006; 6:761.
- Jutel M, Akdis M, Blaser K, Akdis CA. Are regulatory T cells the target of venom immunotherapy? Curr Opin Allergy Clin Immunol 2005; 5:365.
- 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.
- Schiavino D, Nucera E, Pollastrini E, et al. Specific ultrarush desensitization in Hymenoptera venom-allergic patients. Ann Allergy Asthma Immunol 2004; 92:409.
- Müller U, Hari Y, Berchtold E. Premedication with antihistamines may enhance efficacy of specific-allergen immunotherapy. J Allergy Clin Immunol 2001; 107:81.
- Roll A, Hofbauer G, Ballmer-Weber BK, Schmid-Grendelmeier P. Safety of specific immunotherapy using a four-hour ultra-rush induction scheme in bee and wasp allergy. J Investig Allergol Clin Immunol 2006; 16:79.
- Sturm G, Kränke B, Rudolph C, Aberer W. Rush Hymenoptera venom immunotherapy: a safe and practical protocol for high-risk patients. J Allergy Clin Immunol 2002; 110:928.
- Cox L, Nelson H, Lockey R, et al. Allergen immunotherapy: a practice parameter third update. J Allergy Clin Immunol 2011; 127:S1.
- Birnbaum J, Charpin D, Vervloet D. Rapid Hymenoptera venom immunotherapy: comparative safety of three protocols. Clin Exp Allergy 1993; 23:226.
- Gorska L, Chelminska M, Kuziemski K, et al. Analysis of safety, risk factors and pretreatment methods during rush hymenoptera venom immunotherapy. Int Arch Allergy Immunol 2008; 147:241.
- Kalogeromitros D, Makris M, Koti I, et al. A simple 3-day "rush" venom immunotherapy protocol: documentation of safety. Allergol Immunopathol (Madr) 2010; 38:69.
- Oren E, Chegini S, Hamilos DL. Ultrarush venom desensitization after systemic reactions during conventional venom immunotherapy. Ann Allergy Asthma Immunol 2006; 97:606.
- 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.
- Patella V, Florio G, Giuliano A, et al. Hymenoptera Venom Immunotherapy: Tolerance and Efficacy of an Ultrarush Protocol versus a Rush and a Slow Conventional Protocol. J Allergy (Cairo) 2012; 2012:192192.
- Brown SG, Wiese MD, van Eeden P, et al. Ultrarush versus semirush initiation of insect venom immunotherapy: a randomized controlled trial. J Allergy Clin Immunol 2012; 130:162.
- Bernkopf K, Rönsch H, Spornraft-Ragaller P, et al. Safety and tolerability during build-up phase of a rush venom immunotherapy. Ann Allergy Asthma Immunol 2016; 116:360.
- Golden DB, Moffitt J, Nicklas RA, et al. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011; 127:852.
- Laurent J, Smiejan JM, Bloch-Morot E, Herman D. Safety of Hymenoptera venom rush immunotherapy. Allergy 1997; 52:94.
- 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.
- Berchtold E, Maibach R, Müller U. Reduction of side effects from rush-immunotherapy with honey bee venom by pretreatment with terfenadine. Clin Exp Allergy 1992; 22:59.
- Reimers A, Hari Y, Müller U. Reduction of side-effects from ultrarush immunotherapy with honeybee venom by pretreatment with fexofenadine: a double-blind, placebo-controlled trial. Allergy 2000; 55:484.
- Müller UR, Jutel M, Reimers A, et al. Clinical and immunologic effects of H1 antihistamine preventive medication during honeybee venom immunotherapy. J Allergy Clin Immunol 2008; 122:1001.
- Arseneau AM, Nesselroad TD, Dietrich JJ, et al. A 1-day imported fire ant rush immunotherapy schedule with and without premedication. Ann Allergy Asthma Immunol 2013; 111:562.
- 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.
- Birnbaum J, Ramadour M, Magnan A, Vervloet D. Hymenoptera ultra-rush venom immunotherapy (210 min): a safety study and risk factors. Clin Exp Allergy 2003; 33:58.
- - Rush
- - Ultra-rush
- ADVANTAGES AND SAFETY OF ACCELERATED IMMUNOTHERAPY
- - Rates of systemic allergic reactions
- CONSENT, STAFFING, AND EQUIPMENT
- Informed consent
- Staffing and equipment
- SPECIFIC PROTOCOLS
- 135 minutes
- 150 minutes
- Four hours
- One day
- Two days
- MANAGEMENT OF ADVERSE REACTIONS
- Systemic reactions
- Large local reactions
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS