Hymenoptera Venom Allergy: Management of Children and Adults in Clinical Practice

Abstract

Hymenoptera venom allergy is an epidemiologically underestimated condition representing an important cause of morbidity worldwide. Preventing future allergic reactions in patients who have developed a systemic reaction is based on the correct management of emergency followed by a correct diagnosis, prescription of adrenaline autoinjectors and, where indicated, specific venom immunotherapy (VIT). Some epidemiological studies highlight the poor knowledge of this disease and the frequent inadequacy of its management. Moreover, they emphasize the importance of such a life-saving treatment as specific immunotherapy. The availability of high quality Hymenoptera venom extracts for diagnostic and therapeutic use has dramatically improved the prognosis and the quality of life of allergic patients. The subcutaneous VIT represents the most effective form of immunotherapy with allergen presently available, with a carry-over effect lasting up to several years after its interruption. This report on the management of children and adults allergic to Hymenoptera venom was drawn up by a panel of Italian experts. The main objective of this consensus is to review the scientific evidences related to diagnosis, therapy and management of patients allergic to Hymenoptera venom and is aimed to improve the knowledge about this disease and promote good clinical practices. Practical suggestions for a correct diagnosis, prescription of emergency therapy and immunotherapy, as well as strategies for taking care of patients´ management are included.

Development of a model care pathway for the management of Hymenoptera venom allergy: evidence-based key interventions and indicators

“…Seventeen publications, among which six were international guidelines, were identified from literature search, which were screened for identification of all possible statements/recommendations [3,[6][7][8][16][17][18][19][20][21][22][23][24][25][26][27][28].…”

“…Diagnosis (D) D1 [28] History includes the description of the symptoms and of the course of the reaction (possibly documented by a medical report), the number of stings, the characteristics of the culprit insect (where possible) and the identification of specific risk factors for the severity of reaction [28] Allergy to bumble bees, due to its low aggressiveness, concerns a limited number of subjects, in particular professionally exposed individuals [8], and it should therefore be investigated on the basis of a specific anamnestic suspicion, provided that a suitable extract is commercially available for diagnosis In case of a suspected clinical history, perform diagnostic investigations for Bumble bee also with the aim of prescribing a possible VIT I12, I13…”

“…Pharmacological treatment (TF) PT1 [7] Adrenaline is potentially lifesaving and must therefore promptly be admin- Aspiration of adrenaline from a vial is time-consuming and the delay may prevent the beneficial effects of the drug; therefore, AAIs are recommended Prescribe adrenaline in autoinjector device I19 PT5 [28] In obese or overweight patients, the reduced length of the needle does not always ensure the intramuscular administration, therefore the patient should be advised to press well the autoinjector on fatty thigh, to compress it and allow the penetration of the needle into the muscle Instruct obese patients to press well the autoinjector on fatty thigh to compress it and allow the penetration of the needle into the muscle I19 PT6 [28] If a correct dosage is administered, it can be used, without absolute contraindications, in pediatric and geriatric populations and in cardiopathic patients, except for some cardiac pathologies such as for example long QT syndrome Glucocorticoids in the treatment of anaphylaxis potentially relieve protracted anaphylaxis symptoms and are thought to prevent biphasic anaphylaxis, although these effects have never been proven Administer corticosteroids to relieve protracted anaphylactic symptoms (however not in adrenaline replacement) and probably to prevent biphasic anaphylaxis, although this effect has never been proven with controlled randomized trials I2 PT24 [7] Patients may receive a set of tablets containing an adequate dose of a rapidly effective non-sedating oral antihistamine (e.g. levocetirizine 10 mg, cetirizine 20 mg, or double dose for children according to the age) and corticosteroids (e.g.…”

“…levocetirizine 10 mg, cetirizine 20 mg, or double dose for children according to the age) and corticosteroids (e.g. prednisone: for adults 50-100 mg and 1-2 mg/kg body weight in children [28] In children with only cutaneous systemic reactions, VIT is not routinely performed. However, there may be particular situations of increased risk of re-sting (e.g.…”

“…This should be a shared decision with consideration of high-risk factors (frequent exposure, cardiovascular or respiratory conditions, or selected medications) and the effects on quality of life Advise both children (and caregivers) and adults who have experienced only cutaneous systemic reactions after an insect sting that VIT is generally not required. VIT can be considered when there are special circumstances (cardiovascular or respiratory conditions, effects on quality of life) I20 VIT15 [28] In patients allergic to Hymenoptera venom, in whom a subsequent allergic reaction may be more severe or even fatal, VIT has an elective indication even if there has been a myocardial infarction or a severe ventricular arrhythmia Suggest VIT in cardiopathic venom allergic patients when a systemic reaction occurred I20, I21…”