Allergic reactions after vaccination: translating guidelines into clinical practice

Abstract

Background. Ultra-rush (UR) are induction protocols used in venom immunotherapy (VIT). Objectives. To evaluate the adverse reactions during a 210-minutes UR and determine possible risk factors. Methods. Retrospective study of 129 patients submitted to UR with VIT in the last 20 years. Results. In 114 (88.4%) patients, the 101.1 μg maintenance dose was reached in 210 minutes. Systemic reactions (SR) occurred in 22% of patients (71% mild). There were no severe SR, late reactions or fatalities. Adrenaline was administered in 10% of all UR. The SR were more frequent with honey bee VIT and had greater severity in the patients with a previous severe systemic sting reaction. No significant difference in the risk of SR was found with other demographic, clinical or laboratory factors. There were 5% of large local reactions (LLR), these being more frequent in females. Conclusion. Most SR during UR were mild with no need for adrenaline treatment. The honey bee venom and the severity of the anaphylaxis during the field sting were the only SR's risk factors for systemic adverse reactions during the UR. VIT is usually administered by subcutaneous injections with aqueous extracts and comprises an induction phase and a maintenance phase necessary to ensure a sustained effect over time (1). Since its development, several induction protocols have been proposed for VIT. These protocols differ from one another in the time required to reach the maintenance dose and in the interval between the injections (8,9,10). The risk of a new systemic sting reaction implies the need for the patient to reach the protection dose as quickly as possible. Thus, slow, conventional protocols with an induction period of 4 to 6 months and intervals between doses of 3 to 7 days have been progressively replaced by faster protocols (11,12). The latest include cluster or rush-modified protocols in which induction lasts generally 6 weeks (administration of 2 injections separated for 30 minutes every 3 to 7 days), rush protocols in which the induction lasts less than a week and the ultra-rush (UR) protocols in which the induction may last from 120 minutes to 2 days with doses being administered at intervals ranging from 20 minutes to 2 hours (11,12,13).

Managing systemic reactions and venom immunotherapy in vespid-venom allergy: observations from a retrospective study of Portuguese patients

“…sensitization, compared to the reported 27.3% (24). We believe that this variance may be attributed to differences in environmental exposure in our country, as highlighted in previous studies (5,6,23,25).…”

Segurança do protocolo ultra-rush na imunoterapia a venenos de himenópteros: Avaliação de fatores de risco para reações adversas

“…No entanto, pautas convencionais são associadas a melhor tolerância do que pautas rápidas 13,25 . Ainda assim, diversos estudos têm mostrado que protocolos rápidos (rush e UR) são pelo menos tão seguros quanto protocolos mais lentos, sendo uma mais-valia para os doentes pela sua conveniência 8,11,12,[15][16][17][18][19] . 13,25 , por oposição aos outros dois, que apontam protocolos rush como seguros 16,27 .…”

“…Apesar da sua maior conveniência, permanecem dúvidas em relação à segurança, uma vez que alguns estudos associaram protocolos mais rápidos a uma maior incidência de RA sistémicas 13,14 . Porém diversos outros estudos demonstraram que protolocos UR são, pelo menos, tão seguros quanto os convencionais 11,12,[15][16][17][18][19] . Assim sendo, permanece ainda controvérsia e receios quanto à sua segurança, sobretudo dado o pouco conhecimento sobre fatores de risco para RA ao tratamento com VIT.…”

<p>Clinical Utility of Rush Venom Immunotherapy: Current Status</p>

“…Regarding the ultra-rush protocol, systemic reactions range from 7% to 22%. 56, [73][74][75] The vast majority of systemic reactions are mild and do not need medication. 76 However, life-threatening anaphylaxis and fatal anaphylaxis have been described, 77 and the build-up phase should be managed by trained health care professionals able to start resuscitation if needed.…”

“…80 Bee VIT clearly increases the risk of reactions compared to vespid venom. 70,74,80 Before VIT, measurement of baseline serum tryptase concentration should be used to identify patients with a high risk for side effects. Moreover, mastocytosis is a significant determinant for VIT failure.…”