10/31/2012
64 yo male normally in excellent health; no h/o resp allergies or food allergies. Seeking opinion regarding potentially starting pt on venom immunotherapy.

Pertinent history:
- approximately 5 separate honey bee stings as a child and teen (no reaction).
- ~ 5 yrs ago: 5-6 HB stings at the same time (no reaction)
- early summer 2012: HB sting on butt with a 2" hive-like rxn that remained localized to area of sting.
- August 2012: HB sting to right bicep; he removed stinger immediately. Gradual swelling of arm over next 12 hrs. Swelling, redness, and induration extended from the shoulder to the wrist; very pruritic. No other symptoms. Seen in an Urgent Care Center: IM & oral steroids + Benadryl. All resolved without complications.
- Saw pt for first time following this sting rxn. Is a friend & neighbor. Skin testing was scheduled based on the history.
- Prior to coming in for the testing, he was stung again by a HB on the lateral aspect of tongue while cycling. He called me & I went over to his house armed with oral meds. Unilateral tongue swelling only. Administered 30 mg of Orapred ODT + 50 mg of Benadryl. Swelling started to subside. Then developed swelling all along the lower gum line/jaw line as the tongue swelling resolved; difficulty speaking d/t swelling. No pharyngeal swelling; no resp difficulty. He took a total of 50mg additional Orapred over the next 6 hrs and 50mg of Benadryl (was attending a family wedding that afternoon). I watched him in house until all was stable. Swelling resolved 100% over next 3 hrs. No other complications. Waited 3 weeks to do testing.
- Venom skin test: 1cm wehal and 2 cm flare to HB at 0.001 ug intradermal. Remainder of panel to other stinging insects was negative.
- HB RAST = class 4.

Summary: Multiple HB stings in past without consequence. Large local reaction in August. Oral swelling to sting on tongue in Sept. Pts without a sensitivity to HB would most likely have a fair amount of swelling with a tongue sting. What are your thoughts on starting VIT in this pt? He is now armed with Orapred and Benadryl; I will be giving him an Epi as well. Thanks.

Thank you for your inquiry.

Your patient has experienced multiple large local reactions to hymenoptera stings. Normally this would not be an indication for allergen immunotherapy, and the issuance of an epinephrine autoinjector is left to the clinical judgment of the physician caring for such a patient. However, it has been shown that immunotherapy can reduce the severity of large local reactions as you can see from the abstract copied below, and this is mentioned also in the most recent revision of the practice parameter on insect sting hypersensitivity (1).

Therefore, if you feel, as is seemingly becoming evident, that insect stings in his case will occur frequently because of his lifestyle, then certainly immunotherapy can be instituted as discussed in the abstract of the paper copied for you below. The immunotherapy procedure would be identical to that which would be administered to a patient who has had a systemic event. And, as mentioned, the issuance of an automatic epinephrine injector is also an option. If you do institute immunotherapy, I believe I would also prescribe an automatic epinephrine injector to this patient.

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

Reference:
1. Golden D, et al. Stinging insect hypersensitivity: a practice parameter update 2011. J Allergy Clin Immunol 2011 (April); 127(4):852-854.

Abstract:
J Allergy Clin Immunol. 2009 Jun;123(6):1371-5. Epub 2009 May 13. Venom immunotherapy reduces large local reactions to insect stings.
Golden DB, Kelly D, Hamilton RG, Craig TJ.
Source
Johns Hopkins Asthma and Allergy Center, Baltimore, MD, USA.
Background: Large local reactions to insect stings cause significant morbidity and impair quality of life. Venom immunotherapy is not recommended because of a low risk for future systemic reaction and unproven efficacy in preventing large local reactions.
Objective: To determine the feasibility of performing a controlled trial to examine the efficacy of venom immunotherapy in reducing the size and duration of large local reactions.
Methods: Sting challenge in 41 patients with previous large local reactions and positive venom skin tests caused large local reactions 16 cm or larger in 34 patients, and 29 consented to treatment. Venom immunotherapy was initiated in 19, and 10 were untreated controls. Sting challenge was repeated after 7 to 11 weeks (control patients then began venom immunotherapy), and annually for as long as 4 years.
Results: After 7 to 11 weeks of treatment, the size and duration of large local reactions decreased 42% and 53%, respectively, in treated patients and 18% in controls (P < .01 for both). The response was similar after 1 year, and improved after 2 to 4 years to 60% and 70%, respectively.
Conclusions: Venom immunotherapy significantly reduced the size and duration of the large local reactions, and the efficacy improved over a period of 2 to 4 years of treatment. Further studies are needed to establish the safety and efficacy of venom immunotherapy for large local reactions, the optimal duration of treatment, and the mechanism for the differences in degree and rate of clinical response compared with venom immunotherapy in systemic reactors.

Sincerely,
Phil Lieberman, M.D.