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