Hymenoptera Venom Immunotherapy

Beatrice M Bilò; Floriano Bonifazi

Disclosures

Immunotherapy. 2011;3(2):229-246. 

In This Article

Efficacy

Subcutaneous VIT is probably the most effective allergen treatment currently available to physicians. The efficacy of VIT has been confirmed in prospective controlled and uncontrolled studies[2,10] and in one meta-analysis (level of evidence Ia),[71] demonstrating that the protection rate of vespid VIT is higher than that offered by honeybee VIT.[72]

The recommended maintenance dose is 100 µg of venom, both in children and adults. This dose was originally proposed because it was believed to be equivalent to two stings. Indeed, between 50 and 140 µg venom are delivered by a bee sting compared with up to 3 µg by that of a Vespula sting and up to 17 µg by that of a Polistes sting.[1] This standard dose prevents SRs in 75–95% of patients who are re-stung[10] and provides better protection than a 50-µg dose in adults.[4] For the first time, a recent paper demonstrated the efficacy of a P. dominulus extract after a field sting.[65]

A dose of 200 µg is recommended when a SR follows an insect sting in spite of VIT with 100 µg and in highly exposed populations, such as beekeepers.[2,10] According to some authors, an elevated maintenance dose (usually 200 µg) from the start of VIT should be administered to honeybee allergic patients with concomitant mastocytosis and also considered in vespid venom allergic subjects with additional risk factors.[51]

Most American patients receive mixed vespid venoms, with an injectable maintenance dose of 300–400 µg, which provides approximately 98% protection.[31,47]

The protection rate of bumblebee VIT, demonstrated by sting challenge and in-field stings, is estimated to be higher than 90%.[68]

Some authors have demonstrated that VIT efficacy in mastocytosis sufferers may be reduced.[52,73] Two female patients died following a yellow jacket re-sting despite VIT, which nevertheless occurred several years after discontinuing immunotherapy.[74] Contrarily, this indicates that patients with mastocytosis should continue lifelong VIT, increasing the dose, where possible.[52] Moreover, there is a venom-specific effect of baseline tryptase concentration. Higher tryptase levels do not seem to play a role in patients with honeybee allergy but may have an effect in patients with vespid venom allergy.[75]

Box 2 presents risk factors currently known to predispose a patient to a SR at sting challenge or an in-field sting during VIT.

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