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These reactions, including anaphylaxis, can be severe and fatal even on the first exposure.1 Systemic reactions occur in approximately less than 1 percent of children, compared with around 3 percent of adults.3 Systemic reactions to a sting are most often IgE-mediated.1
Allergic reactions to bee or wasp venom can also be localized to the sting and can vary in severity.1 Patients experiencing a large local reaction will usually experience edema, erythema, and pruritus rapidly after the sting.1 These symptoms typically peak between 24 and 48 hours after the sting.1
Systemic reactions can be measured using the World Allergy Organization Subcutaneous Immunotherapy Systemic Reaction Grading System, with severity ranges from grade I to grade IV:5
Diagnostic tests should be carried out in all patients with a history of a systemic sting reaction to detect sensitization. As venom immunotherapy (VIT) is indicated in patients with a history of severe systemic reactions and documented sensitization, it is imperative to correctly identify the offending insect.
International guidelines recommend that tryptase should be analyzed in patients with a history of a severe sting reaction and that tryptase should be measured in patients before starting VIT. 2, 6-9
Tryptase measures the total tryptase levels including all forms of α-tryptase and ß-tryptase. The baseline level of tryptase in the circulation reflects the number of mast cells. Elevated baseline levels of tryptase are an indication of mastocytosis and measurement of tryptase is recognized by the World Health Organization (WHO) as a minor diagnostic criterion of the disease.10
Allergy to insect venom has been reported to cause emotional distress in patients leading to a decrease in their quality of life,4 so communicating the most effective management strategy can help alleviate the fear associated with another potential reaction.
Stinging insects most likely to cause a reaction may include:4
Adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis to 90 percent.i,ii Conventionally, a diagnosis of allergic or autoimmune disease relies on the case history and a physical examination. However, adding diagnostic testing to aid in a differential diagnosis has been shown to increase confidence in diagnosis.i,ii Diagnostic testing can also help to improve the patient’s quality of life and productivity, reduce costs associated with absenteeism, and optimize use of medication, in addition to decreasing unscheduled healthcare visits.iii,iv
i. Duran-Tauleria E, Vignati G, Guedan MJ, et al. The utility of specific immunoglobulin E measurements in primary care. Allergy. 2004;59 (Suppl78):35-41.
ii. NiggemannB, Nilsson M, Friedrichs F. Paediatric allergy diagnosis in primary care is improved by in vitro allergen specific IgE testing. Pediatr Allergy Immunol. 2008;19:325-331
iii. Welsh N, et al. The Benefits of Specific Immunoglobulin E Testing in the Primary Care Setting. J Am Pharm Assoc. 2006;46:627.
iv. Szeinbach SL, Williams B, Muntendam P, et al. Identification of allergic disease among users of antihistamines. J Manag Care Pharm. 2004; 10 (3): 234-238
Venom immunotherapy (VIT) is the go-to treatment option for patients with a venom allergy. It has been shown to reduce the risk for future systemic reactions and the severity of a systemic reaction when one occurs.5 That is why guidelines recommended VIT as an option for the treatment of IgE-mediated bee and wasp venom allergy in patients who have had a:7
VIT is most appropriate for patients with a sensitization to bee and wasp venom, as such, making a distinction between cross-reactivity and genuine double-sensitization is critical.2,7,11,12 Up to 50 percent of venom-allergic patients have positive whole allergen test results to both bee and wasp venom extracts.12 Successful VIT is more likely when treatment selection is based on specific sensitization to bee and/or wasp venom.7
Practice parameters have been developed to help guide the management and treatment of patients with venom allergies.