Q:

3/13/2019
A 46 year-old male presented with the question of whether he should undergo another course of venom immunotherapy. At age 13, he had been stung and had a systemic reaction with throat tightness, hives, and swelling. He received venom immunotherapy for 11 years following that episode. While undergoing venom IT he was stung twice and did not have adverse reactions.

He has not been stung since then, and has always carried injectable epinephrine, but now he is concerned because he will be starting to work as an umpire and will be spending more time outdoors.

Immunocap testing was as follows: Honeybee 1.21 kU/L, white-faced hornet 0.99, yellow jacket 0.71, paper wasp 0.67, and yellow hornet 1.07. Skin testing has not been performed.

Total IgE is 487 and he also has dust mite, pollen, pet, and mold allergies that he does not wish to treat.

Serum tryptase is 4.

Would you recommend proceeding with another course of immunotherapy based on the above history and testing, given that he still has positive serum IgE testing?

A:

At the 2019 AAAAI Annual Meeting there was a Saturday afternoon session on "Taking a Closer Look at Venom Immunotherapy from Several Angles". Hanneke Oude Elberink MD PhD gave an excellent talk on "Who really needs venom immunotherapy". She outlined the risks and benefits of venom immunotherapy (VIT) and noted:

1) VIT does not prevent fatal reactions
2) Most reactions are of the same severity
3) VIT is effective, but the frequency of stings is so low, the ability of VIT to prevent anaphylaxis is also very low
4) VIT is highly effective in reducing resting reactions, except in mastocytosis
5) VIT improves the quality of life
6) There is no burden of treatment
7) There is high adherence
8) Mastocytosis patient are at very high risk and should be considered for life-long VIT

Given the apparent lack of mastocytosis in this patient there is no strong indication for VIT, other than the effect it will have on the quality of life for the patient and his parents. The bottom line is it is a quality of life calculation that needs to be worked out between the patient, his family, and the treating allergist.

I hope this information is of help to you and your patient.

Regards,
Eric Macy, MD, MS, FAAAAI

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