Q:

8/13/2013
I have 42 yrs old female (outdoor person) who recently had two near fatal hymenoptera (one with HB & second YJ sting) sting anaphylaxis. She is pan-allergic (+ high sIgE) to HB, all Vespids & Wasp: Normal Tryptase. Due to cost, safety issues and time frame she is requesting 3-4 days Rapid VIT.

I have reviewed three studies with protocols:
1) Bernstein JA, Kagan SL, Bernstein DI, Bernstein IL. Rapid venom immunotherapy is safe for routine use in the treatment of patients with Hymenoptera anaphylaxis. Ann Allergy 1994;73:423-8.

2) Birnbaum J, Charpin D, Vervloet D. Rapid Hymenoptera venom immunotherapy: comparative safety of three protocols. Clin Exp Allergy 1993;23:226-30, (IIa).

3) Birnbaum J, Ramadour M, Magnan A, Vervloet D. Hymenoptera ultra-rush venom immunotherapy (210 min): a safety study and risk factors. Clin Exp Allergy 2003;33:58-64

I am not clear from the protocols if they used "all" common VIT? In my patient HB, Mixed Vespids & Wasps will be used. Will appreciate further recommendations. Thx

A:

Thank you for your inquiry.

I have also looked at the literature in response to your inquiry to see if I could find a study specifically using all venoms, and was unable to do so. I did find, however, one study employing honeybee and wasp simultaneously. Most such studies, as you found on your review, deal with single venoms.

However, I have no reason to believe that the side effect profile of using all venoms would differ from that of using one or two varieties. I know of no data comparing the side effect profile of these two strategies.

If, however, you are concerned about the safety of using all venoms simultaneously, you could divide the treatment into two protocols; for example, treat with honeybee and then with mixed vespid and Polistes or with honeybee and Polistes (as in the article copied below), and then with mixed vespid. Since rush protocols can be completed within a few days, this would only lengthen her therapy a short period of time, and since the amount of venom itself would not differ, you could consider not charging for the administration itself during the second protocol which would keep costs the same as if you had done all venoms simultaneously.

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

Allergol Immunopathol (Madr). 1995 Nov-Dec;23(6):277-84.
Venom immunotherapy: tolerance to a 3-day protocol of rush-immunotherapy.
Díez Gómez ML, Quirce Gancedo S, Juliá de Páramo B.
Source
Servicio de Alergia del Hospital, Ramón y Cajal de Madrid, España.
Abstract
In the last 10 years in the Ramón y Cajal Hospital, in Madrid, we have treated 78 patients who had presented anaphylactic reactions after hymenoptera stings, by means of a rush immunotherapy protocol. Fifty patients received wasp venom and 30 received honeybee venom (2 patients were treated with both venom types). Venom immunotherapy is given to out-patients, at the hospital, in the morning. The interval between injections administered on the same day is 30 minutes and the patient stays for 2 hours under observation after the last daily dose. The schedule we use is as follows: Day 1 (0.05-1-5-10 micrograms of venom), Day 2 (20-40 micrograms), Day 3 (40-60 micrograms), Day 5 (100 micrograms). Afterwards, they receive 100 micrograms after 2 weeks and, finally, monthly. In order to achieve a better tolerance, patients are protected with antihistamines on the days they are administered the immunotherapy (mequitazine 5 mg every 12 hours) and also, doses equal or over 40 micrograms are given fractionally, injecting half dose in each arm. The percentage of systemic reactions (mild or moderate) is 13.3% for patients treated with honeybee venom and 2% for patients treated with wasp venom. These percentages are lower than those obtained with conventional protocols in which it takes several weeks to reach the maintenance dose. The speed and convenience of this protocol and also its appropriate safety have led us to use it as a routine treatment for patients who require venom immunotherapy after suffering anaphylactic reactions due to hymenoptera stings.

Sincerely,
Phil Lieberman, M.D.

AAAAI - American Academy of Allergy Asthma & Immunology