Insect Sting Allergy

New Guidelines From the European and USA Consensus Groups: Algorithms and Recommendations

David B.K. Golden


Curr Opin Allergy Clin Immunol. 2019;19(5):456-461. 

In This Article

Abstract and Introduction


Purpose of review: Guidelines on insect sting allergy and venom immunotherapy (VIT) have been updated. This review describes the evolution of these guidelines and their similarities and differences.

Recent findings: The US and European guidelines show the evolution of guideline development in the grading of recommendations and the transparency of the evaluation of evidence. The US and European guidelines on VIT are similar in most areas and complimentary in others. The European guidelines are limited to VIT and are based on a published systematic review; the US practice parameters cover all areas of the diagnosis and management of insect sting allergy and do not use the Grading of Recommendation Assessment, Development and Evaluation (GRADE) approach.

There is general agreement that both children and adults with cutaneous systemic reactions do not require VIT, and that there is minimal risk associated with β-blockers and angiotensin-converting enzyme inhibitors during VIT. There are minor differences in the details of VIT dose, regimen, and choice of venom, but agreement on the duration and risk factors for relapse after VIT. The US and European guidelines are complementary in their discussion of the relation of mastocystosis and insect sting anaphylaxis and the value of measuring basal serum tryptase.

Summary: The updated guidelines on insect sting allergy from the US and European groups differ in scope, with a somewhat different focus in specific areas but are complementary overall. Where they overlap, there are relatively few differences in recommendations, and these are subtle. The US practice parameter offers an annotated algorithm for the evaluation and treatment of patients with reactions to insect stings.


Guidelines for clinical practice (practice parameters) are developed and published periodically to provide a framework for the care of patients with allergic conditions. These guidelines are often regional in nature, are developed or sponsored by national or regional medical societies, and are created to meet a variety of needs. They provide guidance for clinicians on the recommended approaches to the evaluation and treatment of patients and are also a resource for other individuals or groups interested in these recommendations including governmental and regulatory agencies, health insurance companies, pharmaceutical companies, medicolegal professionals, and, of course, our patients. Both the US and European academic allergy organizations have published updated guidelines on insect sting allergy in the past 2 years.[1,2] In this review, I will consider the evolution of guideline development relevant to these new guidelines, the content of these updated guidelines, and the similarities or differences between them.