EAACI guidelines on allergen immunotherapy: Hymenoptera venom allergy

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Abstract

Hymenoptera venom allergy is a potentially life-threatening allergic reaction following a honeybee, vespid, or ant sting. Systemic-allergic sting reactions have been reported in up to 7.5% of adults and up to 3.4% of children. They can be mild and restricted to the skin or moderate to severe with a risk of life-threatening anaphylaxis. Patients should carry an emergency kit containing an adrenaline autoinjector, H1 -antihistamines, and corticosteroids depending on the severity of their previous sting reaction(s). The only treatment to prevent further systemic sting reactions is venom immunotherapy. This guideline has been prepared by the European Academy of Allergy and Clinical Immunology's (EAACI) Taskforce on Venom Immunotherapy as part of the EAACI Guidelines on Allergen Immunotherapy initiative. The guideline aims to provide evidence-based recommendations for the use of venom immunotherapy, has been informed by a formal systematic review and meta-analysis and produced using the Appraisal of Guidelines for Research and Evaluation (AGREE II) approach. The process included representation from a range of stakeholders. Venom immunotherapy is indicated in venom-allergic children and adults to prevent further moderate-to-severe systemic sting reactions. Venom immunotherapy is also recommended in adults with only generalized skin reactions as it results in significant improvements in quality of life compared to carrying an adrenaline autoinjector. This guideline aims to give practical advice on performing venom immunotherapy. Key sections cover general considerations before initiating venom immunotherapy, evidence-based clinical recommendations, risk factors for adverse events and for relapse of systemic sting reaction, and a summary of gaps in the evidence.

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Most cited references 113

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AGREE II: advancing guideline development, reporting and evaluation in health care.

M. Brouwers, M E Kho, G P Browman … (2010)

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Clinical features and severity grading of anaphylaxis.

Michelle Brown (2004)

Existing grading systems for acute systemic hypersensitivity reactions vary considerably, have a number of deficiencies, and lack a consistent definition of anaphylaxis. The aims of this study were to develop a simple grading system and definition of anaphylaxis and to identify predictors of reaction severity. Case records from 1149 systemic hypersensitivity reactions presenting to an emergency department were analyzed retrospectively. Logistic regression analyses of the associations between individual reaction features and hypotension and hypoxia were used to construct a grading system. Epinephrine use, etiology, age, sex, comorbidities, and concurrent medications were then assessed for their association with reaction grade. Confusion, collapse, unconsciousness, and incontinence were strongly associated with hypotension and hypoxia and were used to define severe reactions. Diaphoresis, vomiting, presyncope, dyspnea, stridor, wheeze, chest/throat tightness, nausea, vomiting, and abdominal pain had weaker, albeit significant, associations and were used to define moderate reactions. Reactions limited to the skin (urticaria, erythema, and angioedema) were defined as mild. These grades correlated well with epinephrine usage. Older age, insect venom, and iatrogenic causes were independent predictors of severity. Preexisting lung disease was associated with an increased risk of hypoxia. This simple grading system has potential value for defining reaction severity in clinical practice and research settings. The moderate and severe grades provide a workable definition of anaphylaxis. Age, reaction precipitant, and preexisting lung disease appear to be the major determinants of reaction severity.

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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.

Ulf Darsow, Thomas Hawranek, Werner Aberer … (2009)

Severe anaphylaxis to honeybee or vespid stings is associated with a variety of risk factors, which are poorly defined. Our aim was to evaluate the association of baseline serum tryptase concentrations and other variables routinely recorded during patient evaluation with the frequency of past severe anaphylaxis after a field sting. In this observational multicenter study, we enrolled 962 patients with established bee or vespid venom allergy who had a systemic reaction after a field sting. Data were collected on tryptase concentration, age, sex, culprit insect, cardiovascular medication, and the number of preceding minor systemic reactions before the index field sting. A severe reaction was defined as anaphylactic shock, loss of consciousness, or cardiopulmonary arrest. The index sting was defined as the hitherto first, most severe systemic field-sting reaction. Relative rates were calculated with generalized additive models. Two hundred six (21.4%) patients had a severe anaphylactic reaction after a field sting. The frequency of this event increased significantly with higher tryptase concentrations (nonlinear association). Other factors significantly associated with severe reactions after a field sting were vespid venom allergy, older age, male sex, angiotensin-converting enzyme inhibitor medication, and 1 or more preceding field stings with a less severe systemic reaction. In patients with honeybee or vespid venom allergy, baseline serum tryptase concentrations are associated with the risk for severe anaphylactic reactions. Preventive measures should include substitution of angiotensin-converting enzyme inhibitors.

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Author and article information

Contributors

E.-M. Varga: (View ORCID Profile)

O. Pfaar: (View ORCID Profile)

Journal

Title: Allergy

Abbreviated Title: Allergy

Publisher: Wiley

ISSN: 01054538

Publication date Created: April 2018

Publication date (Print): April 2018

Publication date (Electronic): December 05 2017

Volume: 73

Issue: 4

Pages: 744-764

Affiliations

[1 ]Department of Dermatology and Venerology; Medical University of Graz; Graz Austria

[2 ]Outpatient Allergy Clinic Reumannplatz; Vienna Austria

[3 ]Department of Paediatric and Adolescent Medicine; Respiratory and Allergic Disease Division; Medical University of Graz; Graz Austria

[4 ]The David Hide Asthma and Allergy Research Centre; St Mary's Hospital, Newport, Isle of Wight; NIHR Biomedical Research Centre; University Hospital Southampton NHS Foundation Trust; Southampton UK

[5 ]Clinical and Experimental Sciences and Human Development in Health Academic Units; Faculty of Medicine; University of Southampton; Southampton UK

[6 ]Allergy Clinic; Copenhagen University Hospital Gentofte; Gentofte Denmark

[7 ]Allergy Unit; Department of Internal Medicine; University Hospital of Ancona; Ancona Italy

[8 ]Swiss Institute of Allergy and Asthma Research (SIAF); University of Zurich; Zurich Switzerland

[9 ]Servicio de Enfermedades del Sistema Inmune-Alergia; Departamento de Medicina y Especialidades Médicas; Hospital Universitario Príncipe de Asturias; Universidad de Alcalá; Madrid Spain

[10 ]Department of Pediatrics; Jagiellonian University Medical College; Krakow Poland

[11 ]Department of Internal Medicine, Allergy and Clinical Immunology; Medical University of Silesia; Katowice Poland

[12 ]Department of Dermatology and Allergology; University Medical Center Gießen and Marburg (UKGM); Justus Liebig University Gießen; Gießen Germany

[13 ]Allergy Research Group; Department of Dermatology; Medical Center - University of Freiburg; Freiburg Germany

[14 ]Medical Faculty Ljubljana; University Clinic of Respiratory and Allergic Diseases Golnik; Ljubljana Slovenia

[15 ]Department of Pediatric Pneumonology and Allergy; Medical University of Warsaw; Warsaw Poland

[16 ]Department of Allergology & Clinical Immunology; Mother Theresa School of Medicine; Tirana Albania

[17 ]Faculty of Technical-Medical Sciences; Department of Paraclinical Disciplines; Medicine University of Tirana; Tirana Albania

[18 ]Department of Allergy and Clinical Immunology; 2nd Paediatric Clinic; University of Athens; Athens Greece

[19 ]Department of Infection and Immunity; Luxembourg Institute of Health (LIH); Strassen Luxembourg

[20 ]Department of Dermatology and Allergy Center; Odense Research Center for Anaphylaxis; University of Southern Denmark; Odense Denmark

[21 ]Department of Allergology and Internal Medicine; University of Groningen; University Medical Hospital Groningen & Groningen Research Center for Asthma and COPD (GRIAC); Groningen The Netherlands

[22 ]Department of Otorhinolaryngology, Head and Neck Surgery; Medical Faculty Mannheim; Universitätsmedizin Mannheim; Heidelberg University; Heidelberg Germany

[23 ]Center for Rhinology Allergology; Wiesbaden Germany

[24 ]Medical School; University of Cyprus; Nicosia Cyprus

[25 ]UOC Clinical Allergy and Immunology - IRCCS Foundation Ca’ Granda Ospedale Maggiore Policlinico; Milan Italy

[26 ]Klinik und Poliklinik für Dermatologie und Allergologie; Klinikum der Universität München; Munich Germany

[27 ]Department of Pulmonary Diseases; Division of Immunology and Allergy; Faculty of Medicine; Ankara University; Ankara Turkey

[28 ]Faculty of Medicine; Department of Allergy and Clinical Immunology; Transylvania University Brasov; Brasov Romania

[29 ]Department of Immunology and Allergy; Northern General Hospital; Sheffield UK

[30 ]Department of Pediatrics; Allergy Unit; University of Messina; Messina Italy

[31 ]Molecular Allergology and Immunomodulation-Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin Berlin; Berlin Germany

[32 ]Section of Allergy and Clinical Immunology; Imperial College London; National Heart and Lung Institute; Royal Brompton Hospital; London UK

[33 ]Allergy Department; Hospital Clínico San Carlos; IdISSC; Madrid Spain

[34 ]Hans Christian Andersen Children's Hospital; Odense University Hospital; Odense Denmark

[35 ]Wroclaw Medical University; Wroclaw Poland

[36 ]ALL-MED Medical Research Institute; Wroclaw Poland

[37 ]Department of Pediatric Pneumology and Immunology; Charité Universitätsmedizin; Berlin Germany

[38 ]Departments of Experimental Immunology and of Otorhinolaryngology; Academic Medical Center; University of Amsterdam; Amsterdam; The Netherlands

[39 ]Usher Institute of Population Health Sciences and Informatics; University of Edinburgh; Edinburgh UK

[40 ]Austrian Lung Union; Vienna Austria

[41 ]Section of Allergology; Department of Internal Medicine; Erasmus MC Rotterdam; Rotterdam The Netherlands

[42 ]Evidence-Based Health Care Ltd; Edinburgh UK

[43 ]School of Pharmacy; University of Bradford; Bradford UK

[44 ]Asthma UK Centre for Applied Research; Usher Institute of Population Health Sciences and Informatics; University of Edinburgh; Edinburgh UK

[45 ]Food Allergy Referral Centre Veneto Region Department of Women and Child Health; Padua General University Hospital; Padua Italy

Article

DOI: 10.1111/all.13262

PubMed ID: 28748641

SO-VID: 2bfce150-c54d-4dfb-b140-f27375adce51

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http://doi.wiley.com/10.1002/tdm_license_1.1

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