Seguridad de inmunoterapia con veneno de himenópteros en pauta agrupada: Perspectiva de enfermería

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Abstract

Fundamento. La gravedad inherente a la hipersensibilidad IgE mediada a veneno de himenópteros impone la necesidad de alcanzar, en el menor plazo de tiempo posible, la dosis de mantenimiento en la inmunoterapia con venenos. El objetivo del presente trabajo es valorar la seguridad de una pauta agrupada (cluster) de inmunoterapia subcutánea con veneno de himenópteros, que reduce de 12 a 3 semanas el tiempo necesario para llegar a la dosis de mantenimiento. Material y métodos. El estudio fue realizado en 30 pacientes, 24 varones y 6 mujeres con una media de edad de 46,06 años, que habían sido diagnosticados de hipersensibilidad a veneno de himenópteros y se les había indicado tratamiento con inmunoterapia. Los pacientes recibieron inmunoterapia frente a veneno de himenópteros Pharmalgen® (ALK Abelló), 13 fueron de Apis mellífera, 12 de Véspula spp, y 5 de Polistes spp, con una pauta agrupada que consistió en: día 1 (4µg + 6µg), día 8 (10µg + 30µg) y día 15 (40µg + 60µg). Se valoraron las reacciones ocurridas durante la fase de inicio entre abril de 2005 y febrero de 2008. Resultados. De los 30 pacientes vacunados 2 presentaron reacción local exagerada, otros síntomas inespecíficos en dos ocasiones y 2 más reacción sistémica. Uno tras administrar la dosis de 40µg, presentó reacción sistémica grado III, y el otro tras recibir la dosis de 60 µg, presentó una reacción sistémica grado II. Ambos pasaron a una pauta convencional de administración de inmunoterapia y tuvieron nuevas reacciones de grado III por lo que se les mantiene la inmunoterapia con premedicación con antihistamínicos orales. Discusión. El estudio confirma que la pauta utilizada es segura con una baja incidencia de reacciones adversas, 1,67% presentó reacción local exagerada, 1,11% tuvo reacción inespecífica y 1,11% reacción sistémica.

Translated abstract

Background. The inherent seriousness of IgE mediated hypersensitivity to hymenopteran venoms makes it necessary to reach, in the shortest period of time, the maintenance dose in immunotherapy with poisons. The aim of this article is to evaluate the safety of a cluster schedule of subcutaneous Hymenopteran venoms immunotherapy, which reduces the time needed to reach the maintenance dose from 12 to 3 weeks. Material and methods. Thirty patients, 24 men and 6 women with an average age of 46.06 years, who had been diagnosed with hypersensitivity to the poison of hymenopterans and for whom immunotherapy had been prescribed participated in the study. The patients received Pharmalgen® (ALK Abelló) immunotherapy against hymenopteran venoms, 13 Apis mellífera, 12 Véspula spp, and 5 Polistes spp, with a cluster schedule that consisted of: day 1 (4µg + 6µg), day 8 (10µg + 30µg) and day 15 (40µg + 60µg). The reactions occurring during the starting phase between April 2005 and February 2008 were evaluated. Results. Of the 30 vaccinated patients 2 presented an exaggerated local reaction, there were other non-specific symptoms on two occasions, and another 2 presented systemic reaction. One following administration of the dose of 40µg presented a grade III systemic reaction, and the other after receiving the dose of 60µg presented a grade II systemic reaction. Both passed to a conventional model of immunotherapy administration and had new grade III reactions, and were therefore kept on immunotherapy with premedication with oral antihistamines. Discussion. The study confirms that the model employed is safe with a low incidence of adverse reactions, 1.67% presented an exaggerated local reaction, 1.11% had an non-specific reaction and 1.11% a systemic reaction.

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Most cited references 22

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Long-term protection after stopping venom immunotherapy: results of re-stings in 200 patients.

U Müller, H. Lerch (1998)

Venom immunotherapy (VIT) protects most patients allergic to Hymenoptera stings while booster injections are continued. Few data on long-term protection after discontinuation of treatment are available. We sought to investigate protection from re-stings over a prolonged period after stopping VIT. Re-sting data were obtained from 200 of 322 patients in whom VIT had been stopped between 1988 and 1992 after a duration of at least 3 years. The 25 (12.5%) patients who again developed systemic allergic reactions were compared with 50 matched patients without re-sting reactions. Clinical data and diagnostic parameters (i.e., skin sensitivity and specific IgE and IgG) were studied. Of the 25 patients who had re-sting reactions, 19 had been treated with bee venom (relapse rate, 15.8%), and six had been treated with Vespula venom (relapse rate, 7.5%). About half of the re-sting reactions occurred on the first resting after stopping VIT. Most of these reactions were mild, whereas the majority of reactions occurring after repeated re-stings were severe. When re-sting reactions were related to the total re-stings per year, an accumulation of sting reactions was observed in years 3 to 5 after stopping VIT. Patients with re-sting reactions had been receiving VIT for a significantly shorter duration (43.35 months) than those with continued protection (54.65 months) (p < 0.01). Of the diagnostic parameters, only a negative intracutaneous skin test at 10(-3) gm/L predicted long-term protection reliably. Venom immunotherapy of 3 to 5 years duration induces long-term protection in most patients. In rare occasions severe re-sting reactions may, however, occur, especially after repeated re-stings.

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Rush Hymenoptera venom immunotherapy: a safe and practical protocol for high-risk patients.

C. Rudolph, Birger Kränke, Gunter Sturm … (2002)

Hymenoptera venom immunotherapy in allergic patients is a well-established treatment modality for the prevention of systemic anaphylactic reactions caused by insect stings. A variety of therapy regimens exists, from conventional to rush and ultrarush modalities that operate on continuous or intermittent schedules. The aim of this study was to report the 8-year experience with our rush venom immunotherapy regimen in predominantly high-risk patients and to compare data on safety and convenience with the results of 26 studies published from 1978 to 2001. One hundred one patients allergic to bee, yellow jacket, or hornet venom were treated with rush Hymenoptera venom immunotherapy. Diagnosis and selection of patients for venom immunotherapy were carried out according to the recommendations of the European Academy of Allergology and Clinical Immunology. We used a 4-day regimen, and the incidence and nature of systemic reactions (SRs) were documented. Fifty-two patients were treated with honeybee venom, and 49 were treated with yellow jacket venom. One hundred (99%) patients reached the maintenance dose. We observed 8 injection-related SRs (0.47% of all injections given) in 7 (6.9%) patients. The number of SRs was higher in patients treated with bee venom extract (12%) compared with in patients receiving yellow jacket venom extract (2%). There was no significant difference in the risk of SRs between female and male patients. The incidence of SRs was considerably lower than the average of 17.8% reported in the literature. With a rush immunotherapy regimen over a time period of 8 years in predominantly high-risk patients, the incidence of SRs was low, despite the high number of patients with bee venom allergy, who are more likely to have side effects. Epinephrine as rescue medication was never necessary, and the regimen proved to be safe and convenient for both the patients and the medical staff.