Consider referral of patients with systemic reactions suspected or possibly caused by insect stings for accurate identification of specific allergen and consideration for venom immunotherapy (or whole-body extract in case of fire ant) |
Up to 3% of the population is at risk for anaphylaxis to insect stings, with approximately 40 documented deaths annually (Chafee, 1970; Settipane & Boyd, 1970; Antonicelli, Beatrice Bilo, & Bonifazi, 2002; Golden, 1989; Charpin, Birnbaum, & Vervloet, 1994; Barnard, 1973; DeShazo, Butcher, & Banks, 1990; Freeman et al., 1992). |
II, III, IV |
Diagnostic
Indirect outcome (avoidance, early pharmacologic treatment of reaction, immunotherapy) |
Patient identification of the specific insect species causing an allergic reaction is frequently incorrect. |
Allergy testing and history-test correlation can more accurately identify specific insects responsible for an allergic reaction and can be helpful in diagnosis, treatment, and avoidance recommendations (DeShazo, Butcher, & Banks, 1990; Hunt et al., 1976; Rueff et al., 1996; Georgitis & Reisman, 1985; Golden et al., 1997; Golden et al., 2001; Moffitt, Barker, & Stafford, 1997; Oude Elberink & Dubois, 2003; Reisman, 1994; Portnoy et al., 1999; Moffitt et al., 2004). |
II, III, IV |
Skin testing is generally preferred over in vitro testing for the initial evaluation of venom-specific IgE antibodies (Golden, 1989; Charpin, Birnbaum, & Vervloet, 1994; Golden, 2001; Oude, 2003; Portnoy et al., 1999; Moffitt et al., 2004; Valentine, 1993; Valentine, 1984; Schwartz et al., 1981). |
II, IIII, IV |
Venom immunotherapy (or fire ant whole-body extract) greatly reduces the risk of systemic reactions in stinging insect–sensitive patients (Settipane & Boyd, 1970; Antonicelli, Beatrice Bilo, & Bonifazi, 2002; Charpin, Birnbaum, & Vervloet, 1994; Feeman et al., 1992; Oude Elberink & Dubois, 2003; Hunt et al., 1978; Triplett, 1973; Valentine, Schuberth, & Kagey-Sobotka, 1990). |
Ib, II, III, IV |
Venom immunotherapy can prevent death caused by subsequent stings in hypersensitive patients (Antonicelli, Beatrice Bilo, & Bonifazi, 2002; Charpin, Birnbaum, & Vervloet, 1994; Oude Elberink & Dubois, 2003; Sasvary & Muller, 1994). |
III, IV |
Consider referral of patients with systemic reactions suspected or possibly caused by biting insects for accurate identification of specific allergen |
Biting insects, such as Triatoma species and mosquitoes, have been identified as a cause of systemic reactions (Feingold & Benjamin, 1961; Hoffman, 2003; McCormack et al., 1995; Rohr, Marshall, & Saxon, 1984; Simons & Peng, 2003.) |
II, III, IV |
Diagnostic
Indirect outcome (avoidance, appropriate pharmacologic therapy) |
RASTs and skin tests to Triatoma species salivary gland extracts and whole-body extracts of other biting insects have been used to identify antigen-specific IgE in sera of hypersensitive patients (Gauci et al., 1990; Hoffman, 2004; Peng et al., 1998; Peng, Yang, & Simons, 1995; Pinnas, Chen, & Hoffman, 1978; Reunala et al., "Frequent occurrence of IgE", 1994; Reunala et al., "Passive transfer of cutaneous", 1994, Shan et al., 1995; Trudeau et al., 1993; Van Wye et al., 1991). |
III, IV |
Patient education by an allergist-immunologist, including the cause of the allergy, specific avoidance measures, recognition and treatment of anaphylaxis, and management of local side effects, might reduce patient anxiety and potentially reduce morbidity from future bites (Feingold & Benjamin, 1961; Hoffman, 2003; McCormack et al., 1995; Rohr, Marshall, & Saxon, 1984; Simons & Peng, 2003). |
II, III, IV |
Consider referral of patients receiving venom (or fire ant whole-body extract) immunotherapy annually for review of interval history, tolerance of immunotherapy, need for repeat testing, and need for continued therapy |
Regular review of interval history, immunotherapy dosing schedule, and adverse events can contribute to reduced complications of treatment (Portnoy et al., 1999; Moffitt et al., 2004). |
IV |
Indirect outcome (avoidance, early pharmacologic therapy, immunotherapy) |
Regular review might identify new comorbidities or medications that increase the risk of poor outcomes from natural stings or insect immunotherapy reactions (Portnoy et al., 1999; Moffitt et al., 2004; Hepner et al., 1990; Hermann & Ring, 1997; Simon, Potier, & Thebaud, 1996; Toogood, 1988). |
II, III, IV |
Assessment of reactions to interval stings can be used to monitor the effectiveness of immunotherapy and might be cause for consideration of changes in dose and schedule (Portnoy et al., 1999; Moffitt et al., 2004; Golden et al., 1981; Rueff, Wenderoth, & Przybilla, 2001; Tracy et al, 1995; Reisman & Livingston, 1992). |
II, III, IV |
The interval between maintenance dose injections can be increased to 4-week intervals during the first year of immunotherapy and eventually to every 6-12 weeks in some patients (Portnoy et al., 1999; Moffitt et al., 2004; Reisman & Livingston, 1992; Goldberg & Confino-Cohen, 2001). |
II, III, IV |
Many patients can safely discontinue venom immunotherapy after at least 3-5 years of treatment, although some patients might need to continue immunotherapy indefinitely. An allergist-immunologist with experience in treating patients with insect venom allergy is best suited to facilitate individualized patient decisions (Portnoy et.al., 1999; Moffitt et al., 2004; Golden et al., 1981; Golden, Kwiterovich, & Kagey-Sobotka, 1996; Golden, Kagey-Sobotka, & Lichtenstein, 2000; Golden et al., 1998; "The discontinuation of Hymenoptera," 1998; Hauguaard, Norregard, & Dahl, 1991; Keating et al., 1991; Lerch & Muller, 1998; Light, 2001; Muller, Berchrold, & Helbring, 1991; "The diagnosis and management of anaphylaxis," 1998; Reisman, 1993; Ross, Nelson, & Finegold, "Effectiveness of specific immunotherapy in the treatment of hymenoptera venom," 2000). |
II, III, IV |