Q:

1/6/2014
I have a 57 yo gentlemen who had an adverse reaction to multiple bee stings as a teenager. He recalls developing diffuse swelling of areas where he was stung with swelling of his tongue and throat. Stings since that time have not produced any reactions. 3/30/06 he had skin testing positive at 1.0ug/ml for Honey Bee and Wasp. He has been receiving VIT for Honey Bee and Wasp since 4/20/06. There was some difficulty getting IgG levels over 3.5mcg/ml for a couple of years. I have not considered stopping VIT due to the honey bee being a culprit and the reaction severity. He has not been re-skin tested since the initial test. Over the last several years he has had difficulties with Coronary Artery Disease, Type II Diabetes, and Hypertension. Some of his medicines now include Lisinopril, Metoprolol, Nitrostat, and Isosorbide. His cardiologist and Family Doctor prefer not to discontinue these meds. I have read the guidelines that say Beta Blockers may be used in these special cases of Hymenoptera Sensitivity, but there is concern for the Lisinopril. Do you think I can discontinue the VIT after almost 8 years? I know honeybee allergy is a risk factor. I am not sure if you would classify his reaction as severe enough to require life time therapy and have the risk of the above cardiac meds.

A:

Thank you for your inquiry.

This type of situation is one where there are no definitive guidelines, and you might get different answers from different consultants. So all I can offer you is an opinion in this regard based upon an analysis of the factors that impinge upon your decision. Based on your letter, I think that you have analyzed those factors very well, but I will go through them.

1. The fact that he is on a beta-blocker and lisinopril places him at an increased statistical risk for a reaction, and also at increased statistical risk for a severe reaction. On the other hand, the fact that he has been able to tolerate immunotherapy quite well while on these drugs is encouraging. Taken together, however, I feel that his use of these medicines would tend to suggest continuation of immunotherapy.

2. The nature of his reactions only questionably indicated that immunotherapy should be initiated in that he did not have hypotension, generalized urticaria, or respiratory symptoms. And he has been stung without an event. In addition, he has been taking injections for 8 years. These point toward the fact that he might discontinue injections without risk.

3. As you mentioned, honeybee reactions traditionally indicate an increased risk of recurrence, and if we gave this fact a value, it would point toward continuing injections.

Thus, we have conflicting factors, and the best one can do is try and take them as a whole and make a judgment call.

My personal opinion, since he is doing well and clearly unable to stop his cardiovascular drugs, would be to "not rock the boat." That is, I probably would continue injection treatment. But, as mentioned above, I believe that one could argue equally well for discontinuing his injections, and other consultants might express this view.

Finally, the only other thing that one might do to clarify the issue further is repeat his skin tests, and if they were negative, do a serum specific IgE to honeybee and wasp. If these, too, were negative, it would probably shift the balance to discontinuation of injections. If these were positive, I believe it would reinforce my original opinion. However, I would see no harm, if you did not want to put him through this testing, in simply continuing his injections as you have in the past.

Thank you again for your inquiry and we hope this response is helpful to you.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology