Stinging insect hypersensitivity: a practice parameter update 2011.

These parameters were developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma & Immunology (AAAAI); the American College of Allergy, Asthma & Immunology (ACAAI); and the Joint Council of Allergy, Asthma and Immunology. The AAAAI and the ACAAI have jointly accepted responsibility for establishing "Stinging insect hypersensitivity: a practice parameter update II." Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task Force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or the ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma and Immunology. This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. These parameters are not designed for use by pharmaceutical companies in drug promotion. The Joint Task Force understands that the cost of diagnostic tests and therapeutic agents is an important concern that may appropriately influence the work-up and treatment chosen for a given patient. The Joint Task Force recognizes that the emphasis of our primary recommendations regarding a medication may vary, for example, depending on third party payer issues and product patent expiration dates. However, since a given test or agent's cost is so widely variable, and there is a paucity of pharmacoeconomic data, the Joint Task Force generally does not consider cost when formulating Practice Parameter recommendations. In extraordinary circumstances, when the cost benefit of an intervention is prohibitive as supported by pharmacoeconomic data, commentary may be provided.

Anaphylaxis to Stinging Insect Venom.

Hymenoptera stinging insects are common culprits for allergic reactions. Anaphylaxis to insect stings can be life threatening and is associated with a significant risk of recurrence. Insect allergy requires referral to an allergist/immunologist for education and for diagnostic evaluation that will direct further management and treatment. Venom immunotherapy is safe and effective; it prevents sting anaphylaxis in up to 98% of patients. Potential risk factors for side effects during testing and treatment should be assessed for every patient to mitigate risk and to guide treatment recommendations and the duration of immunotherapy.

Hymenoptera Venom Extracts in Clinical Practice.

Venom immunotherapy is the only treatment for the prevention of anaphylaxis and remains the prototypical model for its diagnosis and management. Unlike other causes of anaphylaxis, such as foods and drugs, preventative treatment using venom immunotherapy is highly effective with well-established protocols, and is widely available. Hymenoptera venoms are also unique in that the primary allergens are directly measurable in terms of micrograms, rather than labeled on the basis of potency. As such, venoms were the first truly standardized extracts. However, Hymenoptera venom presents unique challenges in collection, processing, and stabilization of the venom extract product. Historically, there have been minor variations in insect composition in venom extract content. These differences were in part based on variation in insect availability and venom collection and have created minor challenges. However, it is a recognized need that venom extracts contain an optimal and complete repertoire of relevant venoms so as to be assured of appropriate diagnosis and treatment. As such, insect availability and collection, as well as storage, stability, and sterility of venom extracts, have remained critical components to appropriate diagnosis and prevention of venom-induced anaphylaxis. In recent years there has been concerns about adequate supplies of venom for appropriate diagnosis and treatment of venom allergy, but these concerns seem to have stabilized, with the movement to a single venom supplier. This movement to a single supplier may provide its own challenges.

A 'difficult' insect allergy patient: reliable history of a sting, but all testing negative.

PURPOSE OF REVIEW: Few conditions are as treatable as allergy to stinging insects, with venom immunotherapy (VIT) providing up to 98% protection to subsequent stings. The challenge with VIT is not in the treatment, but in the diagnosis. To offer VIT, one must determine a history of a systemic reaction to a stinging insect in conjunction with the presence venom-specific IgE. Current diagnostic methods, although sensitive and specific, are imperfect, and some newer testing options are not widely available. A conundrum occasionally faced is the patient with a reliable and compelling history of a systemic allergic reaction yet negative venom-specific testing. This diagnostic dilemma presents an opportunity to consider possible causes for this diagnostic challenge. RECENT FINDINGS: Our evolving understanding of the role of occult mast cell disease may begin to help us understand this situation and develop appropriate management strategies. Venom-specific skin testing has long been the cornerstone of the evaluation of venom sensitivity and is often combined with in-vitro assays to add clarity, but even these occasionally may fall short. Exploring novel venom diagnostic testing methods may help to fill in some of the diagnostic gaps. Do currently available venom vaccines contain all the key venom species? Are there enough differences between insect species that we may simply be missing the relevant allergens? What is the significance of the antigenicity of carbohydrate moieties in venoms? What is the role of recombinant venom extracts? SUMMARY: VIT is the definitive treatment for insect allergic individuals. To utilize VIT, identification of the relevant Hymenoptera is necessary. Unfortunately, this cannot always be accomplished. This deficiency can have several causes: a potential comorbid condition such as occult mast cell disease, limitations of currently available diagnostic resources, or testing vaccines with an insufficient coverage of relevant venom allergens. Exploring these potential causes may help to provide important insight into this important diagnostic conundrum. The use of a case report may help clarify this challenge.

Insect anaphylaxis: where are we? The stinging facts 2012.

PURPOSE OF REVIEW: Insect allergy remains an important cause of morbidity and mortality in the United States. In 2011, the third iteration of the stinging insect hypersensitivity practice parameter was published, the first being published in 1999 and the second in 2004. Since the 2004 edition, our understanding of insect hypersensitivity has continued to expand and has been incorporated into the 2011 edition. This work will review the relevant changes in the management of insect hypersensitivity occurring since 2004 and present our current understanding of the insect hypersensitivity diagnosis and management. RECENT FINDINGS: Since the 2004 commissioning by the Joint Task Force (JTF) on Practice Parameters of 'Stinging insect hypersensitivity: a practice parameter update', there have been important contributions to our understanding of insect allergy. These contributions were incorporated into the 2011 iteration. Similar efforts were made by the European Allergy Asthma and Clinical Immunology Interest Group in 2005 and most recently in 2011 by the British Society of Allergy and Clinical Immunology. SUMMARY: Our understanding of insect allergy, including the natural history, epidemiology, diagnostic testing, and risk factors, has greatly expanded. This evolution of knowledge should provide improved long-term management of stinging insect hypersensitivity. This review will focus primarily on the changes between the 2004 and 2011 stinging insect practice parameter commissioned by the JTF on Practice Parameters, but will, where appropriate, highlight the differences between working groups.

Insect allergy.

Anaphylaxis is a life-threatening allergic condition. The 3 most common triggers for anaphylaxis are food, medications, and insects. All of these triggers are the sources of considerable morbidity and mortality, but of the 3, only insect allergy is treatable through means other than trigger avoidance. Because ≥ 40 deaths per year are attributed to insect stings, it is critical that healthcare providers and the public understand the proper diagnosis as well as the long-term treatment of this potentially life-threatening allergy. Unlike food and medication allergy, which are managed primarily by allergen avoidance, Hymenoptera allergy is managed prospectively using venom immunotherapy; this results in a protective level of up to 98%. Insects of the order Hymenoptera include bees, wasps, hornets, yellowjackets, and ants. They are responsible for the majority of the fatal and near-fatal sting events. Understanding the biology and habitat of the various Hymenoptera species is helpful in recommending insect-avoidance strategies. The diagnosis of insect allergy relies on a history of a systemic allergic reaction with appropriate testing for venom-specific immunoglobulin E. If the history of a systemic reaction to an insect sting and the presence of venom specific immunoglobulin E is confirmed, venom immunotherapy is indicated. The proper and primary means of treating acute anaphylaxis is immediate epinephrine-and studies suggest that it is underutilized in the acute setting. However, it is venom immunotherapy, a disease-modifying therapy, that provides the affected individual with the most effective protection against future sting reactions. Long-term management of insect allergy and anaphylaxis includes appropriate referral to an allergist familiar with insect allergy and, if indicated, venom immunotherapy.

Insect anaphylaxis: addressing clinical challenges.

PURPOSE OF REVIEW: Few allergic reactions are as potentially life-threatening, or frightening to the patient, as anaphylaxis. Food, medications, and insect stings are the three most common triggers of anaphylaxis, but insect allergy provides the best opportunity to understand the biology of anaphylaxis. If the physician can establish a diagnosis of insect allergy, treatment with nearly 98% effectiveness can be initiated. However, sometimes patients have a compelling history of insect sting anaphylaxis, but negative skin and blood tests. This situation presents us with a fascinating opportunity to understand the biology of insect anaphylaxis. RECENT FINDINGS: Recent and ongoing work shows that occult mast cell disease may be critical in insect anaphylaxis. Mastocytosis, serum tryptase and basophil biology are key elements; genetic markers may potentially help us diagnose at-risk individuals and determine proper treatment. Understanding basophil activation may play an additional role both in diagnosis and knowing when therapy might be terminated. SUMMARY: Mast cell disease, serum tryptase and basophil biology are providing an opportunity to better understand and manage insect allergy. This evolving understanding should improve long-term management of insect anaphylaxis and help us to better understand the clinical dilemma of appropriate management of the history-positive patient in which testing is unable to detect venom-specific IgE. Furthermore, omalizumab's immunomodulatory effects may play a role in difficult-to-treat insect allergy and mastocytosis. Finally, unrelated to these, but still important as an ongoing risk factor, is the continued underutilization of epinephrine for both acute and long-term management of insect anaphylaxis.

Anaphylaxis and insect allergy.

PURPOSE OF REVIEW: Anaphylaxis is an acute-onset and potentially life-threatening allergic reaction that can be caused by numerous allergic triggers including stinging insects. This review focuses on recent advances, natural history, risk factors and therapeutic considerations. RECENT FINDINGS: Recent work suggests that concerns over insect allergy diagnosis continue to exist. This is especially true with individuals who have a convincing history of a serious life-threatening anaphylactic event, but lack the necessary diagnostic criteria of venom-specific IgE by skin test or in-vitro diagnostic methods to confirm the diagnosis. The role of occult mastocytosis or increased basophile reactivity may play a role in this subset population. Additionally, epinephrine continues to be underutilized as the primary acute intervention for an anaphylactic reaction in the emergent setting. SUMMARY: The incidence of anaphylaxis continues to rise across all demographic groups, especially those less than 20 years of age. Fortunately, the fatalities related to anaphylaxis appear to have decreased over the past decades. Our understanding of various triggers, associated risk factors, as well as an improved understanding and utilization of biological markers such as serum tryptase have improved. Our ability to treat insect anaphylaxis by venom immunotherapy is highly effective. Unfortunately, anaphylaxis continues to be underappreciated and undertreated especially in regard to insect sting anaphylaxis. This includes the appropriate use of injectable epinephrine as the primary acute management tool. These findings suggest that continued education of the general population, primary care healthcare providers and emergency departments is required.

Negative venom skin test results in patients with histories of systemic reaction to a sting.

For more than 20 years venom immunotherapy has been the preferred treatment for Hymenoptera allergy and venom skin testing the preferred diagnostic test. Most allergists consider venom skin tests to be highly accurate and interpret a negative venom skin test result to indicate the absence of insect allergy. Furthermore, current practice guidelines do not adequately address the question of how best to manage the patient with a convincing history of insect allergy but negative skin test results. Recent case reports and published studies have forced us to reexamine this important management issue and to consider what role in vitro venom testing might have in the management of insect allergy. We reviewed the current status of what is known about the management of individuals with a history of insect allergy but negative venom skin test results and suggested modifications of current working guidelines.